• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki traumatic vs nontraumatic

Create Wiki
K

kmschwarz

Guest
Messages
35
Location
Huntsville, AL
Best answers
0
Patient in the ER has a CT of the head - indication is trauma, injury, pain. In the final impression, it states that the patient has a subdural hemorrhage.

Does it have to state " traumatic subdural hemorrhage", or because of the indication, can you use common sense to link the impression back to the indication?
 
I believe the indication of "trauma, injury" (as you noted in your post) supports a diagnosis code of traumatic subdural hemorrhage, even if the provider doesn't state that word in the final diagnosis. You are not making any assumptions if it is documented at some point in the record. (Does this answer your question, if I understood it correctly?)
 
You must log in or register to reply here.
Top