Wiki Concussion- Dx help

[kcaskey03]

Hello,
Any suggestions or input on this is greatly appreciated!!

.Concussion occurred two weeks ago and was seen by physician. Follows up 2 weeks later with same physician on the concussion.Entire documentation notes concussion details and screenings for any sxs etc? and briefly notes patient has ADHD and the medication that they are on. The doctor coded this visit as "history of concussion."

I would think to code this as 'concussion (active condition) and code ADHD as secondary since this was also addressed. Others are suggesting to code ADHD as primary dx and then code "hx of concussion" as secondary. Im hesitant on doing this as the primary reason for the visit was the concussion

Thanks for any input!

 

[ksobota]

If the primary reason for the visit is the concussion I would code that first. I would also code it as active or ask the provider to double check.

It sounds to me as if he's still actively treating the concussion. Personal history codes ?explains a past medical condition that no longer exists and is not receiving any treatment, but has the potential for recurrence, and therefore may require continued monitoring." That's about the best explanation I've seen.