# How would you code this?- trauma surgeon



## bill2doc (Nov 19, 2011)

I was summoned to see the pt as the trauma surgeon on duty and was there to perform the emergency assessment trauma eval and critical care management.  Male brought in by ambulance after garage door fell and hit him in the head.  No loss of consciousness but head and neck pain. I was there to perform emergency assessment trauma eval and critical care mangement.

vitals, eyes, ears, cervical spine, nose, oral cavity,mandible, heart, abdomen etc - all normal

There is no evidence of urhter injury, pt monitored in trauma bay when met dischare criteria allowed to return home. 

Total critical care time 50min

I'm tempted to bill 99291 because of the dr. note of Critical care time of 50 min but wonder if another code in place of service 23 is more appropriate???


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## mitchellde (Nov 19, 2011)

i do not see anything in the note provided that shows that critical care was provided.  It just looks like an er assessment.  Is there more to the note than just this?  This note does not say much.


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## bill2doc (Nov 19, 2011)

not much else to note.  Analysis and Plan: Male status pst having garage door fall on his head with persistent neck pain. His cervical spine was able to be cleared using readiographic and clinical criteria. No evidence or further injury. He was monitored in Trauma Bay and when met discharge criteria allowed to return home. Total Trauma and Critical care is 50 minutes.

I have a similar patient that notes an auto accident but no real critical diagnosis that I can pull from the report....all points checked but all cleared, monitored and allowed to go home, althougth the note of critical care time...


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## mitchellde (Nov 19, 2011)

the problem is the patient was not critical on presentation and did not appear to progress to critical.  The critical care time noted was the monitoring in the bay time and could represent the total time the patient was there and the provider cked on him periodically.  Cricical care time has to be face to face with the patient time.  This note does not have much substance and definitely does not represent a critical patient in my opinion.  I am havibg a hard time giving it a level 3 er level and am really more comfortabewith a level 2.


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## Evelyn Kim (Nov 19, 2011)

this is not a critical care episode, only an ER eval and only a level 2 eval at that.  This note does not indicate the patient was even admitted, only monitored and then released.  I would not code critical care in this case.


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## bill2doc (Nov 19, 2011)

Thank you Debra.  Would you consider a 99284 POS 23 as the patient was never really admitted? Thanks so much again!  I think the doc's feel since a patient is coming in by ambulance and called in as trauma that they can bill for critical care....I know that this is not the case so I have to know what to change the code to.


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## karen57 (Nov 19, 2011)

My 2 cents worth...there's not enough detail in the note to justify a level 4; I think 99282 is more appropriate.

Karen Conley, CPC


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## mitchellde (Nov 19, 2011)

bill2doc said:


> Thank you Debra.  Would you consider a 99284 POS 23 as the patient was never really admitted? Thanks so much again!  I think the doc's feel since a patient is coming in by ambulance and called in as trauma that they can bill for critical care....I know that this is not the case so I have to know what to change the code to.



I am getting the barest of a 99282, definitely not a level4.


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## bill2doc (Nov 23, 2011)

Would you explain how you come up with the level?  Someone mentioned to me that there is a point system that is used ????? clueless


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