MDM Risk for concussion

LTibbetts

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I have an er patient that came in with a head injury. the final dx was head injury with concussion. My question is, does the head injury or the concussion fall under the moderate risk of MDM for presenting problems? The statement of "undiagnosed new problem with uncertain prognosis" always leaves me wondering what can actually fit into that description. Other than the generic "ie, lump in breast" explanation they give, can you please give me some other ideas of what may be included in this description or parameters that I can use to gauge what should and should not be able to fit into that category?

Frances or Deb...are you guys out there this morning? If so, any feedback from either of you would be great. You guys are my first line of defense with my E/M coding education & questions.
 

muniasamy

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Dear Friend,
My views is,New problem with signs&symptoms which indicate condition is severe we can go for moderate risk, for example If patient came for Head injury or concussion without sings&symptoms ,Its not fall under the moderate risk bcoz its not has symptoms which indicate damaging of brain strcture (severe vomiting,loss of consciousness,confusion worse head ache)
 
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Hard to say

This is a difficult one ...

I'd be more inclined to think of this as "Acute complication injury" ... although the e.g. given is "head injury with brief loss of consciousness" and from the description you give there's no evidence of LOC, I would still consider a concussion as a complication of the injury.

Of course, the physician could HELP by indicating potential symptoms that would indicate an urgent return to the ER (e.g. patient should return immediately if vomiting, nausea, dizziness, blurred vision, speech disturbance ...)

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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