IS THIS THE INITIAL PRESENTATION OR VISIT OR SUBSEQUENT OR SEQUELA?

lsipos@monument.health

Thanks in advance.... Dr. Gold? Or all the other smart CDI's out there (and coders!)

Patient admitted Nov 24 with traumatic SDH.... Had crani for evac on that first visit in Nov. Now returns with "recurrent hematoma-SDH".... (about 3 weeks ago in office they knew he had bleed but tried to treat medically). Planning another evacuation and placement of subdural peritoneal drain... SAME location.....

MY QUESTION IS; IS THIS THE INITIAL PRESENTATION OR VISIT OR SUBSEQUENT OR SEQUELA.... WHERE DOES THIS LAND???

jULI

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Unknown

Hmmmmm!!

As we know, there are traumatic subdurals that are differentiated in ICD by loss of consciousness, length of this loss and potential for recovery. Nontraumatic subdurals are differentiated by acute, subacute and chronic. The definitions of these three are present in the medical literature that we can find on line. Whether the initial insult is traumatic or not, it is possible for there to be leakage into the space left after drainage of the subdural collection. This will lead to "recurrent" subdural collection. We are not talking here about the length of time for reaccumulation of a nontraumatic SDH but the reaccumulation of blood into the space occurred nontraumatically.

Our case is a traumatic subdural that was drained and nontraumatically reaccumulated, failing nonsurgical management and requiring another intervention. My instinct, as there is no direction in any of the resources yet, is to start with a sequela of a traumatic subdural, which would require as much history as you can get of the original event for the 6th digit, and to follow this with a subacute nontraumatic subdural as the sequela. As you know, the rules for sequelae of trauma is to start with the trauma code with the 7th digit of sequela and then follow it with the specific sequela that occurred. My reasoning is that, regardless of whether the original event was traumatic or not, the reaccumulation is not caused by a new trauma and should not be coded as such - unless it WAS caused by a new trauma. And that history should be readily available.

http://www.ncbi.nlm.nih.gov/pubmed/23708224 and lots of others.

Anyone else? This is a good conundrum.

Dr. G.
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)

johnlaul@yahoo.com

blockquote, div.yahoo_quoted { margin-left: 0 !important; border-left:1px #715FFA solid !important; padding-left:1ex !important; background-color:white !important; } If the injury is still under current active treatment then injury would be considered initial encounter.  It doesn't sound as though this patient  reached the routine recovery phase which would be subsequent.  This isn't a complication resulting directly from the injury, unless stated so, so is not sequela which is the new term for late effects. ~Laurie 

Unknown

Laurie, when the patient has been discharged from the hospital, recovered from the injury, and has been followed for new onset of symptoms due to "complications," it's not initial care. Subsequent would be the option if the "complication" did not occur. I think you'd have to go with sequela.

Robert S. Gold, MD
CEO DCBA,Inc
4611 Brierwood Place
Atlanta, GA 30360

ssalinas

Going way out on a limb here, but think I agree with Laurie on this one.

I am not convinced this should be coded to 'sequela'. More info would be helpful but based on what was provided, initial seems more appropriate. I am not sure the patient had 'recovered' from the injury and that this is a new set of symptoms. Examples given in the guidelines cite scar formation following a burn or deviated septum following fx as sequela.

In reading (and re-reading) some relevant Coding Clinics, I think initial may be more appropriate. Clinics referenced are 2015,1st Qtr pp 3-5, pp 10-11, and pp 12-13.

Please convince me otherwise if you feel I am on the wrong track here.

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.org

Tough one....with details stated, I agree w/ Sharon: INITIAL


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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

sharon.cooper@owensborohealth.org

I would also go with Initial.

Sharon Cooper, RN-BC, CCS, CDIP, CCDS, CHTS-CP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation/Appeals

Owensboro Health Regional Hospital
P.O. Box 20007
Owensboro, KY 42304-0007
Office: 270-417-4612
Cell: 270-316-9088
Fax: 1-270-417-4609