ED Coding and Reimbursement Alert

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: The CPT® coding is straightforward enough. Your ICD-10 code choice, however, could be better focused with some more information about the patient and their injury.

CPT® coding: On the claim, report 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) for the E/M service.

ICD-10 coding: You’re best served rechecking the notes before choosing diagnosis codes for this patient, as more information could lead to a more detailed and descriptive ICD-10 code. When you’re checking the notes, ask yourself these questions:

  • Did the patient lose consciousness?
  • If the patient lost consciousness, how long did it last?
  • Did the patient fall off steps or stairs?
  • Did the patient fall from one level to another?

Then, you’ll choose the most appropriate codes from each of these lists (one code per list):

Concussion

  • S06.0X0A (Concussion without loss of consciousness, initial encounter)
  • S06.0X1A (Concussion with loss of consciousness of 30 minutes or less, initial encounter)
  • S06.0XAA (Concussion with loss of consciousness status unknown, initial encounter)
  • S06.0X9A (Concussion with loss of consciousness of unspecified duration, initial encounter)

Fall

  • W00.0XXA (Fall on same level due to ice and snow, initial encounter)
  • W00.1XXA (Fall from stairs and steps due to ice and snow, initial encounter)
  • W00.2XXA (Other fall from one level to another due to ice and snow, initial encounter)
  • W00.9XXA (Unspecified fall due to ice and snow, initial encounter)

Final word: Once you’ve settled on ICD-10 codes for this encounter, append both of them to 99284 to represent the patient’s condition and the cause of the injury.


Other Articles in this issue of

ED Coding and Reimbursement Alert

View All