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Last Modified: 5/5/2020 Location: FL, PR, USVI Business: Part A, Part B

How to determine further work-up under number of diagnoses

Q. In medical-decision making, how does one determine further work-up under “number of diagnoses”?
A. A key element of the medical-decision making category includes management decisions made by the physician to determine a diagnosis and treatment. Evidence of further work-up within documentation would include: indicating a problem is worsening/probable and/or listing possible management options, advice sought, referrals or consultations, and the initiation of or change in treatment.
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