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TBI Sequela — Outpatient Cognitive Rehab (OT), 38 min
Outpatient Rehabilitation • 29 MDATE OF INJURY
May 28, 2020
DATE OF SERVICE
Mar 12, 2024
DISCIPLINES
OT
CHIEF COMPLAINT
Difficulty planning and sequencing daily tasks; word-finding problems at work re-entry.
HPI
29M, driver in a two-car collision 28 May 2020. Diffuse axonal injury; comatose 6 days, regained pre-injury level of consciousness. Discharged from IRF Aug 2020. Now in outpatient neurorehab for persistent executive-function and cognitive-communication deficits. Medicare entitlement via SSDI since 2022.
EXAM
Alert, oriented. Trail Making B 2 SD below norm. Difficulty initiating multi-step tasks; requires external cueing for sequencing.
MDM / PLAN
OT cognitive intervention targeting executive function (planning, sequencing, self-monitoring) with compensatory strategies (external schedule, checklist). Direct one-on-one contact 38 minutes documented start/stop. Plan of care certified.
PROCEDURE / BILLING NOTE
Therapeutic interventions focused on cognitive function: attention/executive tasks with metacognitive strategy training, 38 min direct 1:1. Stipulated MPFS allowed for this session (97129 x1 + 97130 x2): $71.40.
Coder Workspace
Payer
ANSWER KEY — MICHIGAN AUTO NO-FAULT (PIP)
Show expected codes
97129 x1 -GO
97130 x2 -GO
ICD-10-CM: R41.844, R41.841, S06.2X5S
Allowed: $135.66