Coding ?: Epidural hematoma

We have a denial on an encounter where a patient with spinal stenosis underwent a spinal fusion. She had a subacute compression fx that was not amenable to kyphoplasty because there may be an 'epidural hematoma'
The coder coded this 'epidural hematoma' which ends up coding to 432.0 "nontraumatic extradural hemorrhage". We now have a denial because the insurer states that this code is for intracranial hemorrhage only. This makes sense except that I can't see any other way to code out this condition which was a consideration in her surgical procedure and added complexity to her clinical picture.

Any ideas on a more appropriate code? Usually the auditors replace codes but they did not suggest any other code in this case....



Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • edited April 2016
    The best suggestion I have is 336.1.

    Thank you,

    Angie McKee, RHIT, CCDS, CCS, CCS-P
    AHIMA Approved ICD 10 Trainer
    Clinical Documentation Specialist
    Performance Improvement
    University Hospital
    1350 Walton Way,
    Augusta, Ga 30901

  • edited April 2016
    Good Morning, Katy!
     
    My first question would be, did they document that there "maybe" an epidural hematoma at time of discharge?    I am assuming this is an inpt. record.  If so, according to IP Official Guidelines for Coding & Rporting -Sect. II- H. pg 90 Uncertain diagnoses must be documented at time of discharge in order to be coded.    Therefore, if not documented on the day of discharge ( ie. discharge summary, progress note, order, etc. ) it can not be coded.
     
    If it is documented as still "possible, probable , likely"  at discharge, than........I would want to know if it was traumatic, non-traumatic, postop.....in order to  code differently.  For example 852.41-extradural hem.after injury, no open intraranial wound , no unconsciousness might be for a traumatic hematoma. When I put hematoma in the encoder, and use the unspecified, other, brain, epidural, it takes me to the traumatic code 852.41 as a default.    I am thinking the hematoma needs to be further clarified or was not documented as "probable, possible" at time of discharge.
     
    Hope this is helpful.   Good Luck!

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com
  • edited April 2016
    Yes, it is consistently documented in the H&P, Op note, and discharge summery. It was not traumatic as it was due to the compression fracture as far as I can tell. The issue seems to be that the 432 codes are for intracranial issues and this was not intracranial as they are referring to the epidural space of the spine.

    Angie-I also considered 336.1. It still seems like a strange code and its still a MCC. Its really interesting that they (the auditor) did not make a code suggestion because generally that is what they do.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • edited April 2016
    Angie - That is the possibility I came up with as well.

    From Dorland's
    epidural hematoma, accumulation of blood in the epidural space, due to damage to and leakage of blood from the middle meningeal artery, producing compression of the dura mater and thus compression of the brain. Unless evacuated, it may result in herniation through the tentorium, and death.

    Could the physician be queried for another term? Could it be hematoma > non-traumatic > spinal cord >

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    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
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