He has two new problems w/ workup so get 4+ problem points
Both labs and X-rays ordered so 1 data point for each = 2 data points (NOTE - I can't tell from this note if the doctor personally reviewed the Xrays, so not giving him those points.)
I get a Low Risk for an acute uncomplicated illness or injury
This adds to LOW MDM Which means the most he can get is 99282
If he actually reviewed the X-rays, then it bumps his data points to 3 and the MDM to Moderate.
The patient is NOT critically ill. I believe that the physician felt it medically necessary to perform that full exam / work-up to check for injuries, but that does not mean the patient is critically ill and that the service provided is critical care.
Then there's the history .... at best he has an EPF history with a chief complaint, 3 elements of HPI (context, location and duration) and 1 ROS (no loss of consciousness).
I suppose I might count the paramedic's report as ROS ... in which case I would give 4 elements of HPI (context, location, duration and assoc signs), and extended ROS for the Paramedics survey of resp, cardio and musculoskeletal; and then the patient's past medical history and social history (family history noncontributory does not count for anything). So if I were feeling generous I'd give him a DETAILED history.
So IF his MDM were moderate we could code 99283. But as it stands this is a 99282.
Hope that helps.
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join