Neurology & Pain Management Coding Alert

Question: At the request of an urologist, our neurologist consulted on an inpatient with altered mental status. The patient has urosepsis due to a urinary tract infection, an infection at the site of a ventriculoperitoneal (VP) shunt with suspected cellulitis, and a history of traumatic brain injury. Some of these conditions are out of the ordinary for us. How should I code them? Michigan Subscriber Answer: The primary diagnosis is 780.97 (Altered mental status). Your secondary diagnosis will be 996.63 (Infection and inflammatory reaction due to internal prosthetic device, implant and graft; due to nervous system device, implant and graft). This code would not be linked as primary for your neurologist's inpatient visit as this is not the condition that is chiefly responsible for your physician's E/M services. However, it is a co-existing condition that affects the patient's care. You'll also list V15.52 (History of traumatic brain injury) for the [...]