# MDM/Risk Table in an ED setting



## mwagone1 (Aug 12, 2013)

As a Pennsylvania Auto insurer, we reimburse per Medicare guidelines (at a 110% of Medicare Fees).
I was wondering if anyone could offer some insight in regards to coding head injuries without brief LOC.  We use the Medicare Scoresheet and know that it is only a guide, that we do have to make some clinical inference when it comes to something not specifically mentioned on the scoresheet.  There is some debate as to whether a closed head injury, mild concussion, or even a documented “bump” to the head (which we see a lot in MVA injuries) would allow for Moderate MDM.  I feel that it does, especially since signs and symptoms of concussion could present well after the initial ED visit, however I am finding it difficult to find information supporting my belief.  Any guidance or opinions would be appreciated, or if anyone could direct me to where I might be able to find additional information (one way or the other) I would appreciate it!
Thanks in advance!


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## Mojo (Aug 14, 2013)

It is beneficial to have a committee that addresses this type of scenario for consistency. The MDM can differ depending on the facility or billing company. I have seen a low risk assigned for a bump on the head that requires no work up, Rx or repair beyond steri-strips with no LOC, mental status changes or vomiting. Another facility assigns low moderate for any facial, scalp or head trauma as long as a neurological exam is performed - no work up or symptoms.


When a CT is ordered with blunt trauma to the head, some facilities assign a low moderate for a 99283 for a visit with no neurological symptoms while others assign a high moderate for a 99284.


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## jimbo1231 (Aug 15, 2013)

*Mdm*

I agree with Mojo. this has often been discussed on this forum. The Table of Risk isn't a great tool for Emergency Medicine. But it is what we have. So the kid is a passenger in an MVA, hits his head maybe has another symptom besides LOC, a little dizzyness. Not on risk, but was a detailed Neuro Eaxm done, any glacow scale stuff/ Even without a CT, that would get me to a 3. And certainly with a CT as Mojo mentioned I'm at a 4 with proper documentation. If you have EDs going to a 5 in that scenario they are pushing it, unless there are other injuries which is often the case with MVAs.
And these issues fall out of risk, but did the kid arrive by ambulance, boarded etc Have to factor these items into medical necessity. i also believe the ED physicians are legally bound to minimum standard PEs for an MVA. But you would know better than I do about that.

Jim


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