A 36-year-old male presents to the emergency department for the first time after a motor vehicle accident. He complains of shoulder pain from the seatbelt. He sustained a chest contusion. Th

A 36-year-old male presents to the emergency department for the first time after a motor vehicle accident. He complains of shoulder pain from the seatbelt. He sustained a chest contusion. There was no deployment of the airbag. He was going around a curve and lost control of his vehicle, and struck a tree. The patient struck his head and loss consciousness for approximately five minutes. The physician completes a detailed history and physical examination that includes a complete neurological exam. The medical decision-making is of moderate complexity. X-rays of the shoulder and chest are negative for fracture. They include two views of the chest and a complete examination of the shoulder. The patient is discharged to home and advised to return to the emergency department if there is an increase in pain in the chest and shoulder. The patient and his wife are also provided with a list of neurological signs and symptoms to look for in light of the concussion that would warrant a return to the emergency department. He is instructed to follow up with his primary care physician the following day.
4 ICD-10-CM injury codes including external cause code. No x-ray codes.