Neurosurgery Coding Alert

Question: How do I code a hematoma of the gluteus medius?

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Answer: Definitively answering this question requires full access to the presenting diagnosis. If the patient presented without any additional information than what's listed above, we'd code this under the impression that the hematoma is not a result of trauma.

When it comes to hematoma diagnoses, the immediate first step to take is to determine whether or not an injury has occurred. Most coders might understandably search the ICD-10 index for Hematoma à muscle à code by site under Contusion. However, this is an example of why it's important to browse the entire index under a keyword before reaching a conclusion on the correct diagnosis. Immediately below Hematoma à muscle, you will find Hematoma à nontraumatic à muscle à M79.81 (Nontraumatic hematoma of soft tissue). M79.81 is the correct diagnosis code for a hematoma of the gluteus medius.

Look out: When handling diagnoses involving hematomas, context is absolutely key. If there's no context surrounding the diagnosis, it's safe to assume that a trauma did not occur. However, most experienced coders know that documentation of trauma is often ambiguous, at best. Reference of a "fall" or "MVA" in the indication does not give the coder free rein to assume an injury has, in fact, occurred. In these cases, it's suggested that the coder send the report back to the physician for clarification.

Otherwise, they will face one of the many classic coder's dilemmas in which they are forced to apply a non-traumatic hematoma code to a hematoma that has (probably) occurred as a result of a fall or MVA.