What level of risk would you give...

[jenpudua32]

What level of risk would you give syncope resulting in blunt trauma of the head, neck, chest, abdomen, and a motor vehicle accident? In my opinion, this qualifies as an abrupt change in neuro status since it is a loss of consciousness which is under the high-risk section on the table of risk. What is your opinion?

 

[csperoni]

The risk definition changes slightly depending on whether you are coding for outpatient vs inpatient or ER.
Outpatient no longer considers problems, but rather focus on the treatment/management options. (I assume because problems is now a separate element of MDM).
If this was for inpatient or ER, I would consider the risk high. Just don't forget risk is only 1 element of MDM and MDM is only 1 element of the overall requirements.

 

[jenpudua32]

The risk definition changes slightly depending on whether you are coding for outpatient vs inpatient or ER.
Outpatient no longer considers problems, but rather focus on the treatment/management options. (I assume because problems is now a separate element of MDM).
If this was for inpatient or ER, I would consider the risk high. Just don't forget risk is only 1 element of MDM and MDM is only 1 element of the overall requirements.

Thank you for your reply and I agree. So would you agree that the syncope is an abrupt change in neuro status?

 

[csperoni]

Absent a documented simple or known medical explanation, I would consider a patient losing consciousness while driving high risk.
Situations where syncope itself might not be high risk:
- patient very briefly passed out after seeing blood
- it wasn't actually syncope but rather falling asleep at the wheel
- known existing hypotension or extreme dehydration