Level of risk

LuckyLily

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Patient comes into ED altered and intoxicated. Is not able to give ROS because of mental status. 8 body systems documented. EKG and labs done. After time determined patient is just intoxicated. Impression is alcohol use and cocaine use. My question is, what level of risk would this fall on? I want to code a level 5 because of the altered mental status and the cocaine use, another coder wants to give level 3.

Any thoughts?
 

MSROBtL85

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I was told in training if the pt is unable to convey their own information for a medical reason, which, intoxication is, you can automatically use a level 5. Even if someone were with them to give you the info., could still use a level 5. But, I am still apprentice, so, I would check with others, also.
 

CodingKing

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I was told in training if the pt is unable to convey their own information for a medical reason, which, intoxication is, you can automatically use a level 5. Even if someone were with them to give you the info., could still use a level 5. But, I am still apprentice, so, I would check with others, also.
You can give full credit to History since that requires the patient or those accompanying the patient to be able to properly communicate. You can do an exam and the three components of MDM even if a patient is in a coma so you don't necessarily get automatic credit at the highest level.
 
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