ED Coding and Reimbursement Alert

Question: A 25-year-old male presents complaining of "blackouts" that have occurred within the past two weeks; he says he "forgets time" for about five minutes per blackout, and he has had "five or six" in a 15-day span. The blackouts started occurring after he hit his head while running an obstacle course. The ED physician evaluates patient with comprehensive history and comprehensive exam, focusing on possible late effects of head injury; notes also indicate moderate decision making that includes the ordering of neurologic testing. The final diagnosis is "post traumatic seizures." What is the correct diagnosis code for this encounter?

Massachusetts Subscriber

Answer: The notes indicate that patient probably has late-effect symptoms from a traumatic brain injury (TBI). On the claim, report the following:

• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M service
• 780.33 (Post traumatic seizures) appended to 99284 to represent the patient's convulsions
• E009.4 (Activity involving other cardiorespiratory exercise; obstacle course) appended to 99284 to represent the cause of the patient's injury.