HELP PLEASE, Late effects from MVA in 1997?

ohn0disaster

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I have an encounter for a new 28 year old patient who was involved in an automobile accident in 1997, during which he recieved multiple body injuries including a skull fracture. Apparently, this patient still suffers from quite a few late effects pertaining to his injuries from the MVA. I'm kind of unsure as to how to proceed in coding because, though the doctor specifies that the late effects are due to the MVA in 1997, the doctor does not specify the particular injury that caused the current problems that the patient is dealing with. Under "Late effects" there is no choice for late effects due to MVA NOS.

Subjective:
Initial visit of this 28 year old male patient, who had a motor vehicle accident back in 1997, receiving multiple body injuries including injuries to the brain where he sustained skull fracture, which requires surgery. The patient also had the consequence of problem with right side of his body especially his right hand for which he has been having problems with mobility and some pain, also pain in the low back. The patient was told that he had slipped vertebrae in his low back. The patient also has ever since suffered a seizure disorder for which he is taking medication but ignores the name.

-[doctor goes through patient's medications, social and surgical HX, lab work drawn prior to DOS, and ROS]-

Final Assessment:
1. History of MVA with secondary brain injury.
2. Seizure disorder, last one having been 4 months ago.
3. Tobacco dependency.
4. Chronic low back pain secondary to trauma during MVA.
5. Right hand pain secondary to difficulty in mobility since MVA also.

My thoughts are to code 905.0 and V15.52 for #1 and 2. 305.1 for the tobacco dependency. #4 and 5, I need a bit of guidance on. 'Trauma' is so nonspecific, but I'm thinking 908.9, 724.2 for #4. Diagnosis listed #5, I don't know what to code other than 729.5 for the hand pain. Also, should I code 345.90 along with the 905.0 late effect code? And should I be using MVA E-code for an MVA that was in 1997?

Thanks in advance for any suggestions given!
 

mitchellde

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First I would query the doctor for specifics on the brain injury late effects, we need to know what that is, then code that first instead of the V15.52 with the 905.0 code second.. The the seizure disorder, 345.90 is it part of the brain injury? I would then use either the 908.9 or 905.5 for the other late effects, for #4 use a chronic pain code 338.21 as well as the 724.4, #5 719.44, and 781.2
So
Sequela from Brain Injury
345.90
338.21
724.4
719.44
781.2
905.0
905.5
305.1
E929.0
Since you only get 8 dx per claim you will need to drop 2 , probably the 305.1, and if the seizure disorder is the brain injury late effect I would drop the 905.0 since you have it covered with the 905.5. Should be all good then. Please check my codes first but that is how I would code this.
 
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