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help with level

  1. #1
    Default help with level
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    A child is seen in ER for having fallen and hit head. No meds given or tests performed. The final diagnosis by ER doc is minor head injury, forehead contusion and fall. Could I get other's opinions as what level they would code this?

    Thanks for any help.

  2. #2
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    Default See answers in E/M Forum
    This question was also asked in the E/M Forum where there are a number of replies.

    http://www.aapc.com/memberarea/forum...170#post196170
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

  3. #3
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    Quote Originally Posted by rhblevins61@yahoo.com View Post
    A child is seen in ER for having fallen and hit head. No meds given or tests performed. The final diagnosis by ER doc is minor head injury, forehead contusion and fall. Could I get other's opinions as what level they would code this?

    Thanks for any help.
    Judging by the clinical examples in the CPT, I'd say that if there was a brief loss of consciousness documented, use 99284. Without it, I'd use 99283. Hope that helps!

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