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Neurosurgery Coding Alert

You Be the Coder:

Link Hematoma to Discectomy Fusion

Published on Tue Jul 27, 2010

Question:What diagnosis can I use for "status post anterior cervical discectomy fusion with expanding hematoma of neck"?California SubscriberAnswer:If the current hematoma is not linked with the previously done ACDF surgery, then you would report 920 (Contusion of face, scalp, and neck except eye(s)) as the primary diagnosis; you can also code V45.4 (Arthrodesis status) as the secondary diagnosis to indicate the "status ACDF" condition. If the current "expanding hematoma of neck" is documented as a complication developed after the ACDF surgery and linked to the ACDF, then report code 998.12 (Hematoma complicating a procedure) as the primary code and V45.4 as the secondary dx.
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