RE: [MARKETING] [EXTERNAL] Traumatic Encephalopathy / Encephalopathy due to seizures.
Per my handy dandy ICD-9 manual "Traumatic (postconcussional)
encephalopathy codes to 310.2 (Postconcussion syndrome) which includes
"Posttraumatic brain syndrome, nonpsychotic" and "Status postcommotio
cerebri".
Current traumatic encephalopathy codes to 850.9 (Concussion,
unspecified)
And if traumatic encephalopathy occurs with skull fracture to see
Fracture, skull by site with intracranial injury.
I'm not sure what "SDH" means but this could be the reason it codes this
way and may be a teaching point to your trauma surgeons.
No guidance on the coding clinic but my thought would be if there is no
postictal state documented than encephalopathy could be coded if
present.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
encephalopathy codes to 310.2 (Postconcussion syndrome) which includes
"Posttraumatic brain syndrome, nonpsychotic" and "Status postcommotio
cerebri".
Current traumatic encephalopathy codes to 850.9 (Concussion,
unspecified)
And if traumatic encephalopathy occurs with skull fracture to see
Fracture, skull by site with intracranial injury.
I'm not sure what "SDH" means but this could be the reason it codes this
way and may be a teaching point to your trauma surgeons.
No guidance on the coding clinic but my thought would be if there is no
postictal state documented than encephalopathy could be coded if
present.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence
("I CARE")
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative,
Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley