Decision Making - Additional Workup Planned

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Posts: 44
Joined: Fri Aug 03, 2012 10:22 am

Thu Aug 31, 2017 2:03 pm

Hi. I have a question regarding assessing the Number of Diagnoses/Treatment Options for a new problem to the examiner. If the physician determines additional workup is needed beyond the present encounter but the patient refuses that additional workup, then should that be scored as "no additional workup planned"? Or does the physician still get credit for "additional workup planned", regardless of whether the patient agrees or refuses with that additional workup?

To me, the word "planned" implies that the patient has already agreed to the physician's recommendations prior to the workup reaching the "planned" status. However, at the same time, it doesn't seem fair to me lower the score in that particular area dependent on whether the patient agrees or disagrees, when the physician's cognitive work was the same for the encounter either way.

An example would be a hospital patient with multiple masses and lymphadenopathy found on radiology. Physician wishes to proceed with scheduling biopsy and additional tests, but patient refuses and wants to be discharged from the hospital. "Additional workup planned" or "no additional workup planned"?

Thank you for your help!
Posts: 75
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Fri Sep 15, 2017 1:32 pm

I would think that in an outpatient setting when the order is entered but the patient does not follow-up with getting the order done, the physician would get credit for additional work-up.

I am not sure in an inpatient situation if you don't have an order to back the additional work-up you could give credit. Oftentimes my doctors will say "if xxx then I will order (or consult) yyy" and the order never gets entered because the patient gets better. In this case, I do not give credit. If they come back and place the order or consult, they get credit on the day of the order/consult. If it is at discharge and the patient is given a script and/or instructions to follow-up, I would give credit. The physician did the work, even if the patient didn't do what was recommended.

If they take additional time trying to convince the patient to do the follow-up and why it is important, maybe they could consider billing time for counseling and coordination of care even if the outcome is not successful.
"In any moment or decision, the best thing you can do is the right thing." - T.Roosevelt
Shoshana, BA, CPC, CPMA, CPCO, RRT
Posts: 44
Joined: Fri Aug 03, 2012 10:22 am

Mon Sep 18, 2017 10:06 am

Thank you for your input!
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