Wiki Tbi

[cdement0203@yahoo.com]

Does anyone know if there is a guideline stating that if a SDH (or any TBI) is not documented whether or not the patient had LOC are you suppose to code as without LOC? Encoder Pro is sending you to SDH without LOC, S06.5X0A, but SDH NOS looks like it should be S06.5X9A. Any help will be appreciated!

 

[mph0626@aol.com]

Encoder pro is right,S06.5x9 is for Traumatic subdural hemorrhage NOS, if you do not have more specific information about LOC you have to use that code. No more specific guideline.