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ED Coding and Reimbursement Alert

Reader Questions:

Offer ICD-9 trio for post-TBI patient

Published on Sat Nov 06, 2010

Question: A 25-year-old male presents complaining of "blackouts" that have occurred within the past two weeks; he says he "forgets time" for about five minutes per blackout, and he has had "five or six" in a 15-day span. The blackouts started occurring after he hit his head while running an obstacle course. The ED physician evaluates patient with comprehensive history and comprehensive exam, focusing on possible late effects of head injury; notes also indicate moderate decision making that includes the ordering of neurologic testing. The final diagnosis is "post traumatic seizures." What is the correct diagnosis code for this encounter?Massachusetts SubscriberAnswer: The notes indicate that patient probably has late-effect symptoms from a traumatic brain injury (TBI). On the claim, report the following:99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; a detailed examination; and medical decision making of moderate [...]
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