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Regional Trauma Center professional services coding

  1. Default
    Medical Coding Books
    ANALYSIS AND PLAN/INPRESSION AND PLAN: status post motor vehicle collision with no loss of consciousness, and only a small avulsion to the hand and knee with no evidence of bony or organ injury. His cervical spine as cleared by clinical criteria. There were no indications for outside consultation regarding the care of this patient. He was observed in the trauma bay and when met discharge criteria he was was allowed to return home with instructions for close follow up


  2. #12
    Milwaukee WI
    Default MDM is Low
    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

  3. Default No CC
    I see nothing on that chart that would indicate CC. In fact I don't think you have a 4 due to lack of history.
    All the official language about referral to Trauma Center looks good but your doc has to undersatnd that it has nothing to do with coding guidelines.
    I do work for mostly ED docs and if anything they land on the opposite side, underdervaluing CC services and time.I also do some work for Trauma Surgeons and I think you are dealing a bit with surgeon ego. I think what you can do is review CC guidelines with the doc. And it wouldn't hurt to also revew E&M.


  4. Default
    Thanks to you both. Jim, you are correct. I'm having a hard time getting through to them...I hope I can reach out to you in the future. You are billing exactly what they are asking me to do and I'm GREEN

    Thanks so much

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