Wiki Medical decision making risk of complications table

[apollo06]

In the risk of complications and/or morbidity or mortality portion of MDM, in the high section under presenting problems: Acute or chronic illnesses or injuries that may pose a threat to life or bodily function e.g multiple trauma, acute MI, severe resp distress etc.

We have a sports med provider who feels a 9yo pt who has had a mild concussion since Nov is not getting any better and possibly will be referred to Neuro qualifys for the above risk.
Im struggling with this, I realize its a est dx worsening, didnt order any tests, but he renewed her rx. I come up with a 99214 based on documentation however, do you think its appropriate to place the risk in that category?

 

[Skenyon]

If your provider hasn't already referred the patient out to Neuro, then to me, this would indicate that it is not life threatening. Sounds like your assessment of 99214 is correct.

 

[withem]

I too agree with 99214

 

[MnTwins29]

IMO, key word is "functions"

I would place this at high risk because it is still a threat for certain body functions, even if it isn't life threatening at this point. Given that the girl's systems are still developing and this could have impacts on that growth, I wouldn't have an issue with giving this a high risk.