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Wiki trauma neurosurgery E&M

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Kstrobel

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I have been coding E&M for years with no problems but I am having a hard time coding trauma neurosurgeries. When a patient comes in with many injuries, I realize the neurosurgeon is giving care for only his part of the patients problems, and therefore the exam is limited to the head and/or spine. Plus, if the patient is comatose, there is even 'less' of an exam even though the medical necessity is high. Because of the exam documented it is a low level service. Is this correct? It just does not make sense to me when it is such a high level of medical nec. Also if a ventriculostomy is done- is there a management code for the subsequent days?
Thanks for any help you can give me.
Karen
 
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