help with level

ggparker14

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A child is seen in ER for having fallen and hit head. No meds given or tests performed. The final diagnosis by ER doc is minor head injury, forehead contusion and fall. Could I get other's opinions as what level they would code this?

Thanks for any help.
 

OCD_coder

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Depending on the protocol or your employer - it could be either a 99213 or 99214, no tests were ordered, but usually a detailed exam is done by the physician for head injuries. You could support either level as it is a new problem, but the mechanism could be considered high/moderate.
 

mitchellde

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A child is seen in ER for having fallen and hit head. No meds given or tests performed. The final diagnosis by ER doc is minor head injury, forehead contusion and fall. Could I get other's opinions as what level they would code this?

Thanks for any help.
It really is dependent on exactly what the provider documented, not what the patient came in with. It also matters if you are coding for the physician level or the ER level which you did not specify.
 

RonMcK3

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First, is this a New or Established Patient? The first reply assumes established.

Do the case notes document that this Doc satisfied the requirements for EPF or Detailed in terms of Hx and Exam, as well as documenting the MDM?
 
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ER Visits irrespective of new vs established

First, is this a New or Established Patient? The first reply assumes established.

Do the case notes document that this Doc satisfied the requirements for EPF or Detailed in terms of Hx and Exam, as well as documenting the MDM?
There is NO distinction between new and established PATIENTS in ER visits.

But without seeing the actual documentation, AND knowing whether you are talking about facility vs provider billing, can't tell you what level.

F Tessa Bartels, CPC, CEMC
 

RonMcK3

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There is NO distinction between new and established PATIENTS in ER visits.

But without seeing the actual documentation, AND knowing whether you are talking about facility vs provider billing, can't tell you what level.

F Tessa Bartels, CPC, CEMC
F Tessa,

Thanks for the reminders.
 
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