ED Coding and Reimbursement Alert
Don't let head trauma coding give you a headache
Question: Is minor head trauma a "99282" as it does require a detailed history and physical to evaluate for any intracranial bleed? A "99282" to me is a simple rash that I am not doing very much for. Do they always need labs/x-rays to be a "99284"?
Answer: A minor head trauma would likely score higher than a 99282. CPT® Appendix C examples for ED services offer some guidance to the question.
99283 - Emergency department visit for a healthy, young adult patient who sustained a blunt head injury with local swelling and bruising without subsequent confusion, loss of consciousness or memory deficit.
99284 - Emergency department visit for a 4-year-old who fell off a bike sustaining a head injury with brief loss of consciousness.
Chart documentation will always be the deciding factor in determining the level of service reported. You would probably need some diagnostic workup to support the NOPP for a 99284.
ED Coding and Reimbursement Alert
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