Skull Fracture coding

tholcomb

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A patient was treated for a skull fracture the injury was caused when the snowmobile he was driving off-road hit a tree, there was no evidence of intracranial injury. For skull fracture 801.3 or 800.4 and the E-code E003.9 I'm kinda of confused in regards to the skull fracture I need help.

Thank you,
TH
 

armen

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A patient was treated for a skull fracture the injury was caused when the snowmobile he was driving off-road hit a tree, there was no evidence of intracranial injury. For skull fracture 801.3 or 800.4 and the E-code E003.9 I'm kinda of confused in regards to the skull fracture I need help.

Thank you,
TH
Well, 801.3 is for is a fracture of base of the skull with intracranial hemorrhage, I do not see you stating there was a hemorrhage. 800.4 is for vault of the skull with intracranial injury and you said "no evidence of intracranial injury". What I would do if this would be the only peace of info I got, I would code from 803 category this is NOS since your notes does not give enough info to code more specific Dx. The correct code in this case should be 803.00 other and unqualified skull fractures, closed without mention of intracranial injury,unspecified state of consciousness. If you have more specific info in the note let me know I'll help you to fine a code.
 
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