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
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
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
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
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
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