sdunaway1
Guru
I have had several cases lately where the provider does not know if the hemorrhage is traumatic or non-traumatic. I cannot find an unspecified code to capture this situation. The guidance that I have found if it is unknown is to code on symptoms but that really doesn't work in this case because the hemorrhage is being treated. Does anyone know what classification to default to ?Please see an example below-
77-year-old male who had a right frontal intraparenchymal hematoma revealed on CT imaging on January 9 after being involved in a motor vehicle accident. It was unclear based on the hemorrhage pattern whether the hemorrhage occurred first or was a result of the motor vehicle accident. An MRI of the brain was performed which did not reveal any underlying etiology.
77-year-old male with a intraparenchymal hematoma of unknown etiology after a motor vehicle accident. Highly suspicious for traumatic origins as there has been no underlying mass to explain the hemorrhage. He does also have based on his imaging at the time of his accident a pseudoaneurysm which may require dual antiplatelet therapy. Although the hemorrhage has improved but has not completely resolved I would prefer to wait until his next CTA which is scheduled for February 21. Once that 1 is done we will reevaluate for Plavix initiation. He should continue taking his aspirin in the time being.
77-year-old male who had a right frontal intraparenchymal hematoma revealed on CT imaging on January 9 after being involved in a motor vehicle accident. It was unclear based on the hemorrhage pattern whether the hemorrhage occurred first or was a result of the motor vehicle accident. An MRI of the brain was performed which did not reveal any underlying etiology.
77-year-old male with a intraparenchymal hematoma of unknown etiology after a motor vehicle accident. Highly suspicious for traumatic origins as there has been no underlying mass to explain the hemorrhage. He does also have based on his imaging at the time of his accident a pseudoaneurysm which may require dual antiplatelet therapy. Although the hemorrhage has improved but has not completely resolved I would prefer to wait until his next CTA which is scheduled for February 21. Once that 1 is done we will reevaluate for Plavix initiation. He should continue taking his aspirin in the time being.