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Trauma Patient leaves AMA- e/m code?

  1. Question Trauma Patient leaves AMA- e/m code?
    Medical Coding Books
    Patient comes into ER due to a --4-5 foot fall. evaluated by trauma doctors. (critical care)

    no broken bones- just shock, tenderness, pain and muscle strain. Patient basically gets up and leaves the ER.

    It's unusual to hav a critical care patient seen and sent home from Emergency Dept (or them leaving AMA). 99291 code doesn't work. what should I use???

    Thank you

  2. #2
    Milwaukee WI
    Default What is documented
    Code the E/M service (ER VISIT 99281-99285) based on what is documented.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    my guys are trauma surgeons. can I use the ER codes for them???

  4. Default ER
    If the trauma surgeons treated the patient in the ED then the ED codes are appropriate.
    But I'd be careful about Critical Care. Certainly trauma can require CC, but being treated by a trauma surgeon doesn't automatically mean there was CC. What was the condition of the patient, interventions etc. Was time documented. And the guy did get up and walk away...
    There are occasional cases where CC patients do go home but this is typically after significant treatment, meds and intervention for respiratory issues, arrythmias etc.


    I see you wrote 99291 doesn't work. I'm assuming due to lack of time since the patient went AMA. Again, even if there were 30 minutes not sure it would qualify as CC. Shock is the closest symptom I see to maybe CC. But would need to see more.

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