Closed head injury

katysuegood@gmail.comkatysuegood@gmail.com
edited May 2016 in CDI Talk Archive
Do you query for greater specificity (concussion, TBI, etc) when you see documentation of closed head injury? I'm working on this now and wondering what others are doing.

Thanks!

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

  • robert.hodges2robert.hodges2
    edited May 2016
    I would query for cause and if there was loss of consciousness if it isn't already specified. There are several codes for intracranial trauma, which includes TBI, with specification to location of the brain affected and length of loss of consciousness if any.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov


    ”We are continually faced by great opportunities brilliantly disguised as insolvable problems.” Benjamin Franklin
  • vivian.gannonvivian.gannon
    edited May 2016
    We do! In fact, I am working on a query for this now.

    Vivian


    Vivian E. Gannon RN,CCM,CCDS
    Clinical Documentation  Improvement Coordinator
    Chesapeake Regional Medical Center
    vivian.gannon@chesapeakeregional.com
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Awesome. I'd love to see what you come up with. I am working on some education, documentation tip and a query too...

    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
  • vanessa.falkoffvanessa.falkoff
    edited May 2016
    Nice job Katy, thanks for sharing.

    Vanessa Falkoff RN
    Clinical Documentation Coordinator
    University Medical Center
    Las Vegas, NV
    vanessa.falkoff@umcsn.com
    office 702-383-7322
    cell 702-204-0054
  • wrightnawrightna
    edited May 2016
    I must have missed this along the way? Was attachment shared?
  • jolene.filejolene.file
    edited May 2016
    Nice job, Katy. Thanks for sharing.   I really like the uptodate online references.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

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