new coder needs help with E/M

ggparker14

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I would like other opinions on the number of elements in this history.

History reads: the accident occurred 1 to 2 hours ago. Patient fell out of wheelchair today.No head injury or loc. Patient at baseline per son. She does not verbalize due to history of dense right sided stroke. No vomiting.

thanks for any help.
 
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What's the Chief Complaint?

Would help to also know the chief complaint ... Based solely on what you posted ...
I get three - duration, context, and associated signs/symptoms.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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