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Question: Encounter notes indicate that a patient presented to the emergency department (ED) after being hit by an ice hockey puck. They complain of neck pain, double vision, and a headache that is increasing in intensity. Notes indicate that the patient lost consciousness for five minutes. The ED physician performed the Sports Concussion Assessment Tool (SCAT5) and confirmed that the patient suffered a concussion. How should I report this encounter? Is there a procedure code I can use to report the SCAT5?

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Answer: No, there is no separate CPT^® procedure code for the SCAT5; you’ll roll the work of the test into the overall work units for the evaluation and management (E/M) service, then choose a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set to represent the entire encounter.

Dx coding: When you choose the appropriate-level E/M code, be sure to append S06.0X1A (Concussion with loss of consciousness of 30 minutes or less, initial encounter) to represent the patient’s concussion and W21.220A (Struck by ice hockey puck, initial encounter) to represent the cause of the patient’s concussion.

More on SCAT5: The SCAT5 is one of the more common concussion assessment tools, particularly in athletics. There is an on-field assessment, in which the patient is tested right after the injury (this test will have been administered before the patient reported to the ED). The off-field assessment, which your ED physician performed, consists of symptom evaluation, cognitive screening, neurological screening, balance examination, and delayed recall (patient is asked to recall a list of words mentioned earlier in the exam).

Chris Boucher, MS, CPC, Senior Development Editor, AAPC