Traumatic Subdural Hemorrhage Denial
We recently received a denial, as summarized below:
Patient transferred from an outside hospital for a traumatic subdural hemorrhage - GCS of 15, awake, alert, and no neurological deficits. No where in the chart did it say she lost consciousness nor did it say she did not. The 3M encoder runs you through to the screen below. Our CDRN and coder chose 3. Unspecified- which takes you to the code S065X94 Traumatic Subdural hemorrhage with LOC. The insurance company denied the code, stating it was not supported, as the patient did not have LOC. Code was changed to S065X0A. What does your organization choose if the LOC is not known? (a query would be the ideal solution)
Comments
I would have went with unspecified, as a CDS in this scenario Im unable to identify an impact to the DRG, SOI, and/or ROM which is an area of focus to initiate a query at this time. Im curious how did the change in code impact the final billing of the case?
I agree with your code choice.
Your code choice is further supported by the inclusion term code S06.5X9-, “Traumatic subdural hemorrhage NOS” listed in the ICD-10-CM Tabular List of codes.
My interpretation of this inclusion note is that a traumatic subdural hemorrhage which is not otherwise specified (NOS) regarding with or without LOC, would be assigned to code S06.5X9-.
The ICD-10-CM Official Coding Guideline I.A.11 defines inclusion terms as:
I.A.11. Inclusion terms
List of terms is included under some codes. These terms are the conditions for which that code is to be used.
I agree with your code choice, however, our coding director does not. We received this exact denial, it's a financial change of like $200 on our part. Coding has decided that unless LOC is specified, or there is sufficient evidence for a query, then "without loss of consciousness" is coded.
”Unspecified” refers to unspecified duration of any STATED. LOC. It does NOT refer to unspecified duration of conscious versus unconscious.
Key concept: NO LOC is noted, so one can’t code the LOC as ‘unspecified’. Read the descriptor at this code carefully.
If there is no documented LOC, you can’t assign the code being prompted on your screen shot. The only choice is S06.5X0A.
The coding director is correct. Check the descriptions in the Tabular.
The choice offered by your software as it appears not to match ICD-10-CM.
Paul Evans, RHIA, CCDS
Hey Paul,
So when I look up S065X9 it has an inclusion term of "Traumatic subdural hemorrhage NOS". It does not state with or without consciousness in the inclusion term. My understanding of the guidelines is that NOS is to be considered unspecified.
If the above is true, and traumatic subdural hemorrhage is documented without mention of LOC, why would we not go to this code?
Check the description of the code in the Tabular. What tool are you using? Some of the software does not exactly match the official code set, and that can be a problem in that subtle differences may cause us to assign the incorrect code. I have seen this happen with various coding software systems. You can call me if you want?
415.412.9421
Hey Paul,
I looked it up in our Optum Tabular list and it looks the same. I'm probably better over email if you want to continue :-)
kyle_boyd@parkviewmc.com
This is the exact discussion we are having on our team. When I read the description, it seems to be "unspecified" time of LOC. BUT, it also states "NOS" - so what do we code? Thank you for the feedback above, as it helps to hear that denials are occurring at other places. May I be included in your discussion through email, as I'm curious what others are seeing in their software.