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Wiki Leveling E/M for Concussions (level 3 vs level 4)

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cmedina969800

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I am looking for justification to bill a level 4 (99214) for an OV relating to a concussion and whiplash injury. I feel the diagnosis meets moderate. We don't have any data so we would eliminate that so it comes down to the management. The documentation states that the patient needs to rest and low stimulation. There are no worrisome signs to consider CT, but if worsens, or develops other symptoms like nausea, vomiting, altered LOC, advised to go immediately to ER. Ok for ibuprofen up to 800 mg tid or tylenol 1000mg tid prn.

I agree with the doctor that concussions naturally presents higher risk than a sprained ankle, for example, that usually recommend rest and OTC, but is the verbiage "if worsens, or develops other symptoms like nausea, vomiting, altered LOC, advised to go immediately to ER" enough to consider moderate management?

Thoughts?
 
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