ohn0disaster
Guest
I have an encounter for a new 28 year old patient who was involved in an automobile accident in 1997, during which he recieved multiple body injuries including a skull fracture. Apparently, this patient still suffers from quite a few late effects pertaining to his injuries from the MVA. I'm kind of unsure as to how to proceed in coding because, though the doctor specifies that the late effects are due to the MVA in 1997, the doctor does not specify the particular injury that caused the current problems that the patient is dealing with. Under "Late effects" there is no choice for late effects due to MVA NOS.
Subjective:
Initial visit of this 28 year old male patient, who had a motor vehicle accident back in 1997, receiving multiple body injuries including injuries to the brain where he sustained skull fracture, which requires surgery. The patient also had the consequence of problem with right side of his body especially his right hand for which he has been having problems with mobility and some pain, also pain in the low back. The patient was told that he had slipped vertebrae in his low back. The patient also has ever since suffered a seizure disorder for which he is taking medication but ignores the name.
-[doctor goes through patient's medications, social and surgical HX, lab work drawn prior to DOS, and ROS]-
Final Assessment:
1. History of MVA with secondary brain injury.
2. Seizure disorder, last one having been 4 months ago.
3. Tobacco dependency.
4. Chronic low back pain secondary to trauma during MVA.
5. Right hand pain secondary to difficulty in mobility since MVA also.
My thoughts are to code 905.0 and V15.52 for #1 and 2. 305.1 for the tobacco dependency. #4 and 5, I need a bit of guidance on. 'Trauma' is so nonspecific, but I'm thinking 908.9, 724.2 for #4. Diagnosis listed #5, I don't know what to code other than 729.5 for the hand pain. Also, should I code 345.90 along with the 905.0 late effect code? And should I be using MVA E-code for an MVA that was in 1997?
Thanks in advance for any suggestions given!
Subjective:
Initial visit of this 28 year old male patient, who had a motor vehicle accident back in 1997, receiving multiple body injuries including injuries to the brain where he sustained skull fracture, which requires surgery. The patient also had the consequence of problem with right side of his body especially his right hand for which he has been having problems with mobility and some pain, also pain in the low back. The patient was told that he had slipped vertebrae in his low back. The patient also has ever since suffered a seizure disorder for which he is taking medication but ignores the name.
-[doctor goes through patient's medications, social and surgical HX, lab work drawn prior to DOS, and ROS]-
Final Assessment:
1. History of MVA with secondary brain injury.
2. Seizure disorder, last one having been 4 months ago.
3. Tobacco dependency.
4. Chronic low back pain secondary to trauma during MVA.
5. Right hand pain secondary to difficulty in mobility since MVA also.
My thoughts are to code 905.0 and V15.52 for #1 and 2. 305.1 for the tobacco dependency. #4 and 5, I need a bit of guidance on. 'Trauma' is so nonspecific, but I'm thinking 908.9, 724.2 for #4. Diagnosis listed #5, I don't know what to code other than 729.5 for the hand pain. Also, should I code 345.90 along with the 905.0 late effect code? And should I be using MVA E-code for an MVA that was in 1997?
Thanks in advance for any suggestions given!
