This is a case study. Please answer the 7 questions below in bold letters.
LOCATION: Inpatient, Hospital
PATIENT: Mike Bahs
ATTENDING PHYSICIAN: Loren White, MD
CONSULTANT: Timothy Pleasant, MD
REASON FOR CONSULTATION: Rule out neck injury.
HISTORY: This patient is a 17-year-old male who was involved in a motor vehicle
accident last night. He remembers driving down the road and the next thing he
remembers was trying to reach for his cell phone at a stop sign after the accident. He
does not remember any of the details. The car apparently went off the road and hit a
tree. The patient is amnesiac for the event but does not believe he lost consciousness.
His vehicle was apparently traveling 35-40 miles an hour. There was no report that he
was ejected from the vehicle.
PAST MEDICAL HISTORY: He had childhood asthma.
FAMILY HISTORY: Noncontributory to the present problem.
SOCIAL HISTORY: He chews tobacco. Alcohol use is rare.
EXAMINATION: Vital signs show he is afebrile. Pulse 64. Blood pressure 110/50.
Neurologic: He is awake, alert, and fully oriented. His cranial nerves are grossly intact.
HEENT: His extraocular movements are full. His eyes are conjugate. His pupils are
equal. His facial strength is intact. On motor examination, he has grossly normal motor
strength bilaterally in the upper and lower extremities. His reflexes are normal and
symmetric at the biceps, triceps, and brachioradialis. The ankle jerks and the knee jerks
are normal and symmetric. Gait is not tested. Sensory examination is grossly intact to
light touch. Spine examination: The patient’s cervical collar was removed. He has no
tenderness to palpation of the cervical spine whatsoever.
The x-rays of the cervical spine, as well as the CT scan of the cervical spine, were
reviewed. No fractures or subluxations are noted. CT scan of the head was reviewed,
and it is negative for any intracranial pathology.
IMPRESSION/PLAN: In summary, we have a 17-year-old male involved in a motor
vehicle accident. He has a mild concussive head injury, as evidenced by his amnesia,
and I believe he did lose consciousness for a brief period; however, the exact amount of
time for his loss of consciousness is unknown. There is no evidence of any cervical
spine injury. The patient is neurologically normal. He does not need to wear a cervical
collar. I explained to him and his mother, Gloria, that if the patient develops any
weakness, numbness, or tingling in the arms or legs, trouble with his balance,
sleepiness, vomiting, weakness of one side of the body, or any other symptoms, they
should call their physician immediately.
I want to thank Dr. White for asking me to see this patient.
Abstracting & Coding Questions:
1. What level of history was documented?
2. What level of exam was documented?
3. What is the complexity of the medical decision?
4. Does the documentation support the use of a consultation code?
5. Was the patient the driver or passenger in the motor vehicle?
6. What CPT code(s) would be reported for this case?
7. What ICD-10-CM code(s) would be reported for this case?