Neurosurgery Coding Alert

Make sure your surgeon documents acute, subacute, chronic.

ICD-9 offers a single code for reporting a nontraumatic subdural hematoma, 432.1 (Subdural hematoma, nontraumatic). In 2014, when you implement ICD-10, you will have a choice of more than one code. Follow these fundamentals to improve your reporting of nontraumatic subdural hematoma in ICD-10.

Verify the Age of the Hematoma

ICD-10 necessitates that you determine how old the nontraumatic subdural hemorrhage is. Depending upon whether the hemorrhage is acute, subacute, or chronic, you will choose to report codes I62.01 (Nontraumatic acute subdural hemorrhage), I62.02 (Nontraumatic subacute subdural hemorrhage), or I62.03 (Nontraumatic chronic subdural hemorrhage). "It is nontraumatic subacute and chronic types of subdural hematoma that are typically amenable to treatment by burr hole drainage," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Your surgeon will determine the chronicity of the hemorrhage through history obtained from the patient and then by confirming the density in a CT scan. An acute subdural hemorrhage is one that is less than three days old and appears diffusely hyperdense in the CT scan. A subacute subdural hematoma is 3-21 days old, and a chronic subdural hematoma is more than 21 days old. The chronic hematoma appears diffusely hypodense on a CT whereas a subacute hematoma is usually heterogeneous and isodense.

You will need to ascertain that your surgeon adequately documents the age and the CT density of the subdural hematoma in the clinical note. "Acute hematoma is a new bleed and easy to identify," says Rena Hall, CPC, Kansas City Neurosurgery, North Kansas City, Missouri. "The subacute and chronic hematomas may pose a problem. A subacute hematoma is one that may not require immediate intervention and can be either newly or recently diagnosed.  A chronic hematoma may have necessitated numerous treatments and still continues to be an issue for the patient."

You may also come across an acute bleed in a patient who has a chronic history of a subdural hematoma. Such an acute-on-chronic subdural hematoma appears as areas of hyperdensity within a hypodense hematoma on the CT scan. You report this as acute and file code 162.01 in this case. "This usually occurs after a second head injury in a patient with a previously untreated subdural hematoma or in a patient who did not fully resolve a prior subdural hematoma after surgical evacuation," says Przybylski.

If your surgeon does not document the adequate details for the chronicity of the nontraumatic subdural hematoma, you report code I62.00 (Nontraumatic subdural hemorrhage, unspecified) stating that the precise chronicity of the hemorrhage has not been determined or documented. "It will be important to educate surgeons concerning the need to specify the age of subdural hematomas once the more granular diagnostic codes become available," says Przybylski.