A 4-year-old is brought to the emergency department (ED) by emergency medical services. He had sustained a loss of consciousness after falling from playground equipment. His parents are out of town and the caregiver is unable to provide any history. The ED physician is concerned that the child might be critically injured. A comprehensive physical examination is performed and it is determined that the child is now clinically stable. A pediatric neurologist is called for consultation and admits the child for observation of a concussion.

The ED physician documents the severity of the patient's condition, mental status, and reason that she was unable to obtain a comprehensive history.

How will the physician report her services?

The selection of the level of service for Current Procedural Terminology (CPT®) codes 99281–99285 (ED visit for the evaluation and management [E/M] of a patient) are based on the performance and documentation of...

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