tci ED Coding & Reimbursement Alert - 2023 Issue Q1

Reader Questions: Dig Into Notes for Most Accurate Concussion/Fall Diagnoses

Question: A patient presented to the ED complaining of intense headaches, blurred vision, and nausea after falling in the snow and hitting their head. The provider conducted a concussion questionnaire with the patient and performed an appropriate history and examination. Fearing concussion, the provider ordered a computed tomography (CT) scan, first without contrast then with contrast and further sections. Results of the scan confirmed concussion. Notes indicate that the provider performed high-level medical decision making (MDM) during the evaluation and management (E/M) service, informing the need for the CT scan. How should I code this encounter? California Subscriber Answer: ...

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