Wiki Sequela help!!

[amyllaird]

Sequela Help and clarification appreciated!

Pt has prior TBI resulting in seizure disorder. Guideline state that there is no time limit for sequela.. seizure disorder is being evaluated with no other mention of TBI. In risk adjustment coding, would the TBI still be captured without it being evaluated? I’m very torn on this as I know It itself is not being treated but there is no timeline for sequela and the seizure disorder is the sequela, so wouldn’t both be captured? I do not see how this would be treated differently than a residual effect of a stroke. Any clarification on this is greatly appreciated!

Thank you!

 

[jmjansen]

Would it be possible for you to post the encounter notes? This is interesting to me. If I'm reading your question correctly you are asking, should the seizure disorder, which seems to be a direct result of the TBI, be coded as a sequela? Similar to how we would capture hemiplegia, for example, as as sequela from a stroke.

In the stroke example, for risk adjustment purposes, you are only coding the stroke code during the encounter to which the stroke happened, (most likely in an inpatient stay). Then you are only going to want to capture the hemiplegia, again as an example.

If reading your question above in the same manner, the TBI would be acute (do not keep coding for risk purposes) and you would want to capture the seizure disorder if still being actively monitored or evaluated.

Happy to chat about this more with you if that would be helpful.