Neurosurgery Coding Alert
You Be the Coder:
Link Hematoma to Discectomy Fusion
Published on Tue Jul 27, 2010
Question: What diagnosis can I use for "status post anterior cervical discectomy fusion with expanding hematoma of neck"? California Subscriber Answer: If the current hematoma is not linked with the previously done ACDF surgery, then you would report 920 (Contusion of face, scalp, and neck except eye(s)) as the primary diagnosis; you can also code V45.4 (Arthrodesis status) as the secondary diagnosis to indicate the "status ACDF" condition. If the current "expanding hematoma of neck" is documented as a complication developed after the ACDF surgery and linked to the ACDF, then report code 998.12 (Hematoma complicating a procedure) as the primary code and V45.4 as the secondary dx.
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