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help with level

  1. #1
    Default help with level
    Medical Coding Books
    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
    Location
    Nashville AAPC Chapter
    Posts
    937
    Default
    Depending on the protocol or your employer - it could be either a 99213 or 99214, no tests were ordered, but usually a detailed exam is done by the physician for head injuries. You could support either level as it is a new problem, but the mechanism could be considered high/moderate.

  3. #3
    Location
    Columbia, MO
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    12,531
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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.
    It really is dependent on exactly what the provider documented, not what the patient came in with. It also matters if you are coding for the physician level or the ER level which you did not specify.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Location
    Greater Orlando
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    146
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    First, is this a New or Established Patient? The first reply assumes established.

    Do the case notes document that this Doc satisfied the requirements for EPF or Detailed in terms of Hx and Exam, as well as documenting the MDM?
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default ER Visits irrespective of new vs established
    Quote Originally Posted by RonMcK3 View Post
    First, is this a New or Established Patient? The first reply assumes established.

    Do the case notes document that this Doc satisfied the requirements for EPF or Detailed in terms of Hx and Exam, as well as documenting the MDM?
    There is NO distinction between new and established PATIENTS in ER visits.

    But without seeing the actual documentation, AND knowing whether you are talking about facility vs provider billing, can't tell you what level.

    F Tessa Bartels, CPC, CEMC

  6. #6
    Location
    Greater Orlando
    Posts
    146
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    Quote Originally Posted by FTessaBartels View Post
    There is NO distinction between new and established PATIENTS in ER visits.

    But without seeing the actual documentation, AND knowing whether you are talking about facility vs provider billing, can't tell you what level.

    F Tessa Bartels, CPC, CEMC
    F Tessa,

    Thanks for the reminders.
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

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