Subdural hemorrhage with expansion
Neuro not my forte.
(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows "massive subdural bleed with midline shift and mass effect with intraventricular hemorrhage and brainstem herniation" -- how does this code out? Do you code the subdural hemorrhage traumatic (where bleed originated) or do you code to the level of the intraventricular hemorrhage even though that wasn't the origination point?
(#2) Am I able to also code the compression of brain (brainstem herniation) or is that considered integral to the traumatic hemorrhage injury code and not separately codeable?
Thank you in advance!!
(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows "massive subdural bleed with midline shift and mass effect with intraventricular hemorrhage and brainstem herniation" -- how does this code out? Do you code the subdural hemorrhage traumatic (where bleed originated) or do you code to the level of the intraventricular hemorrhage even though that wasn't the origination point?
(#2) Am I able to also code the compression of brain (brainstem herniation) or is that considered integral to the traumatic hemorrhage injury code and not separately codeable?
Thank you in advance!!
Comments
Laurie
Sent from Yahoo Mail for iPhone
On Friday, April 15, 2016, 12:57 PM, CDI Talk wrote:
Neuro not my forte.
(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows “massive subdural bleed with midline shift and mass effect with intraventricular hemorrhage and brainstem herniation” -- how does this code out? Do you code the subdural hemorrhage traumatic (where bleed originated) or do you code to the level of the intraventricular hemorrhage even though that wasn’t the origination point?
(#2) Am I able to also code the compression of brain (brainstem herniation) or is that considered integral to the traumatic hemorrhage injury code and not separately codeable?
Thank you in advance!!
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 15, 2016 12:36 PM
To: Hoffmeister, Loretta
Subject: Re: [cdi_talk] Subdural hemorrhage with expansion
It is Not intrigal ... Also code venticle hemorrhage if the stated it.
Based on the finding be sure the physician states the correct terms of "brain compression & brainstem herniation" mass effect midline shift don't count
You can also capture the GCS if not sedated with the brain injury & there maybe also comatose opportunity
Laurie
Sent from Yahoo Mail for iPhone
On Friday, April 15, 2016, 12:57 PM, CDI Talk wrote:
Neuro not my forte.
(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows “massive subdural bleed with midline shift and mass effect with intraventricular hemorrhage and brainstem herniation” -- how does this code out? Do you code the subdural hemorrhage traumatic (where bleed originated) or do you code to the level of the intraventricular hemorrhage even though that wasn’t the origination point?
(#2) Am I able to also code the compression of brain (brainstem herniation) or is that considered integral to the traumatic hemorrhage injury code and not separately codeable?
Thank you in advance!!
DISCLAIMER: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for use by the intended recipient. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. The partaking of any action in reliance upon this information by persons or entities other than the intended recipient is illegal and a violation of the regulatory guidance in the Health Insurance Portability and Accountability Act (HIPAA). If you received this in error, please contact the sender immediately and delete the material from all computers.
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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 15, 2016 1:40 PM
Subject: RE: [cdi_talk] Subdural hemorrhage with expansion
Thank you. When I put the brain compression into 3M asked if it was due to trauma and after walking through the tree the only code given was the Trauma/injury code and not an additional code for the compression so I thought maybe with “traumatic injury” it was considered integral and not separately coded. I couldn’t find any guidelines/coding clinics that addressed it though. Appreciate your input.
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, April 15, 2016 12:36 PM
To: Hoffmeister, Loretta
Subject: Re: [cdi_talk] Subdural hemorrhage with expansion
It is Not intrigal ... Also code venticle hemorrhage if the stated it.
Based on the finding be sure the physician states the correct terms of "brain compression & brainstem herniation" mass effect midline shift don't count
You can also capture the GCS if not sedated with the brain injury & there maybe also comatose opportunity
Laurie
Sent from Yahoo Mail for iPhone
On Friday, April 15, 2016, 12:57 PM, CDI Talk wrote:
Neuro not my forte.
(#1) If a patient falls after admission and is positive for subdural hematoma (HAC), and within several hours declines rapidly and ct shows “massive subdural bleed with midline shift and mass effect with intraventricular hemorrhage and brainstem herniation” -- how does this code out? Do you code the subdural hemorrhage traumatic (where bleed originated) or do you code to the level of the intraventricular hemorrhage even though that wasn’t the origination point?
(#2) Am I able to also code the compression of brain (brainstem herniation) or is that considered integral to the traumatic hemorrhage injury code and not separately codeable?
Thank you in advance!!
DISCLAIMER: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for use by the intended recipient. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. The partaking of any action in reliance upon this information by persons or entities other than the intended recipient is illegal and a violation of the regulatory guidance in the Health Insurance Portability and Accountability Act (HIPAA). If you received this in error, please contact the sender immediately and delete the material from all computers.
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Copyright 2013
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DISCLAIMER: The information contained in this transmission may contain privileged and confidential information, including patient information protected by federal and state privacy laws. It is intended only for use by the intended recipient. If you are not the intended recipient, you are hereby notified that any review, dissemination, distribution, or duplication of this communication is strictly prohibited. The partaking of any action in reliance upon this information by persons or entities other than the intended recipient is illegal and a violation of the regulatory guidance in the Health Insurance Portability and Accountability Act (HIPAA). If you received this in error, please contact the sender immediately and delete the material from all computers.
Did this change with ICD-10??
Thanks!
Katy Good
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, May 06, 2016 9:43 AM
To: Kathryn Good
Subject: RE:[cdi_talk] Subdural hemorrhage with expansion
Tagging onto this thread! I thought herniation could be coded separately in traumatic hemorrhages (as opposed to compression) but I just did it and I got an Excludes 1.
Did this change with ICD-10??
Thanks!
Katy Good
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