quick question-truamatic ICH

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
In your opinion, does a provider have to use the term 'traumatic' to specify a traumatic intracranial hemorrhage or is it sufficient to state that the patient fell (for example) and sustained a traumatic ICH. If you have any references for your assertion, that would be great.

I know this sounds like a stupid question. I just need someone to back me up ;-)

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

  • m.leblancm.leblanc
    edited May 2016
    Katy

    I would first ask if your facility has an approved list of medical abbreviations or a policy on abbreviations? My rule of thumb is with a fall and blow to head and when I google for medical abbreviation and if it comes up then probably sufficient. ICH comes up intracerebral hemorrhage. Not sure if this helps?

    Good luck!

    Mark LeBlanc RN, MBA, CCDS
    Director CDI Services
    tWG (the Wilshire Group)

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I guess I wasn’t clear (I should know better!). The issue isn’t with the ICH. It is unabbreviated at times through the record. The issue is the specificity of “traumatic”. Is it necessary that the provider specify that the intracranial hemorrhage is ‘traumatic’ using that term or if the patient fell and had a head injury and this is why they came to the hospital and a intracranial hemorrhage was found/diagnosed, can we code this as a traumatic hemorrhage?

    Thanks Mark!


    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

  • ssalinasssalinas
    edited May 2016
    Hi Katy,

    In my 'just a coder' opinion, it depends on the physician's specific documentation.

    Did the MD say patient fell and sustained ICH? If this was the statement, I would assume traumatic. Or was the statement something to the effect that the patient has an ICH and he fell? Chicken or the egg question here.

    Another aspect of your question: What does ICH stand for in the abbreviation list for your facility? Intracerebral hematoma or Intracranial hemorrhage? From a strict coding perspective, you get 2 different answers/codes depending on if you start with hemorrhage or hematoma. If you start with hematoma (traumatic), brain (traumatic) > 853.0x. If you start with hemorrhage (nontraumatic), brain (nontraumatic) >431. Traumatic is a nonessential modifier for hematoma. Nontraumatic is a nonessential modifier for hemorrhage.

    Will be interested in how others feel about this...

    Thanks,

    Sharon Salinas, CCS
    Health Information Management
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    FAX: 213-202-6490
    ssalinas@barlow2000.org

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    There is no clear precedence that I am aware of in an official coding document that directly answers this, however, I can provide my opinion:

    If the hemorrhage is clearly stated as 2/2 trauma, I use the code for traumatic injury. (pt assaulted, now has ICH).

    Versus – pt lying in bed, experienced symptoms, now has ICH = intrinsic.

    However, the ‘rub’ is that sometimes our staff will state ‘it is not clear if the patient suffered from an intrinsic ICH, leading to a fall ‘with’ trauma, OR, if the pt fell, causing a traumatic ICH”.

    I am given you the worst case scenario, in my practice, I can almost always defend my code selection based on the H&P, ED report, EMS reports, etc.


    PE

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    In this case, the patient tripped and fell over his cat. I agree that if we just have that the patient collapsed, this is a different scenario. The documentation basically says that the patient tripped and fell over his cat, had a contusion, presented to the ER, had a scan and was diagnosed with a small intracranial hemorrhage. Seems pretty clear to me :)

    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

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