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  #1  
Old 07-07-2011, 10:02 AM
selsal selsal is offline
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Question history of subarachnoid hemorrhage

does anyone know a code I can use for history of subarachnoid hemorrhage, or late effect of a subarachnoid hemorrhage? thank you!
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Old 07-07-2011, 05:24 PM
preserene preserene is offline
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It would be more suitable to go for late effect of cerebrovascular disease. - 438 series.
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Old 07-07-2011, 09:56 PM
regina-coder regina-coder is offline
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Default Help getting started

As a CPC -A I need a little help in getting started in the right direction: Radiology Coding

Patient has a history of hysterectomy and rt oophorectomy for a rt ovarian torsion. A US pelvis non OB was done - 76856. US endovaginal scan was done 76860. The Impressions after radiology test/scan were as follows: 1. Uterus and rt ovary have been removed. 2. The lt ovary appears normal. and 3. no significant lesions are seen. What is the dx code ?

Would appreciate your guidance.
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Old 07-08-2011, 06:42 PM
preserene preserene is offline
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Quote:
Originally Posted by regina-coder View Post
As a CPC -A I need a little help in getting started in the right direction: Radiology Coding

Patient has a history of hysterectomy and rt oophorectomy for a rt ovarian torsion. A US pelvis non OB was done - 76856. US endovaginal scan was done 76860. The Impressions after radiology test/scan were as follows: 1. Uterus and rt ovary have been removed. 2. The lt ovary appears normal. and 3. no significant lesions are seen. What is the dx code ?

Would appreciate your guidance.
V71. 8 as primary and V81.6 as secondary diagnosis.

By the way why this thread over to this?!!. I think you should post this on OBGYN section so that you would have more response
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Old 07-08-2011, 08:58 PM
DeeCPC DeeCPC is offline
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Default Actually...more info required

Quote:
Originally Posted by selsal View Post
does anyone know a code I can use for history of subarachnoid hemorrhage, or late effect of a subarachnoid hemorrhage? thank you!
These are two different issues. You can not code late effect unless there is an issue directly related to the subarachnoid hemorrhage. The doctor must document the issues. I believe this is explained in the front of your ICD-9.
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Old 07-09-2011, 11:56 AM
preserene preserene is offline
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yes the doctor has to document the exact word for our coding from the exact word. at times it does not happen. if not able to get to the doctor then what?

Basically hemorrhage in the cranial region occurs due to rupture of the cerebrovascular blood vessels- the reason may be traumatic(trauma) or nontraumatic(which may be a diseased status already like aneurysm, embolic etc) .

Subarachnoid "hemorrhage" (anyhemorrhage) will not stay there for long,(it gets absorbed) to code after a few days /few month/ even years.
The sequlae of the effect of subarachnoid hemorrhage will show up as deseases/ deseased processes consequently- as a desease, signs and symptom as a prolonged effect or as late effect.
Sequencially and subsequently the subarachnoid hemorrhage gets grouped into the cerebrovascular diesases- as I said before, basically hemmorrhage occurs as a result of rupture of the cerebrovascular blood vessel.

If you could code late effects for CVA, then why not for hemorrhage?
But the doctor has document what is the presenting situation/ signs and sympotoms after many days/months/year. In that case, the late effects of cerebrovacular disease could fit in.

As you said, we need more info so that we do not guess the presenting symptoms /sign or the condition for the encounter
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Old 07-11-2011, 09:21 AM
selsal selsal is offline
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the patient is having symptoms due to the hemorrhage, so Im gathering from the posts, that the 438 series codes would fit. The patient had hemorrhage about a month ago, and this is a follow up with neurology.
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