jtrong
New
Hello! Any help and input for this situation is very much appreciated!
I have a new resident coming in from a long hospital stay (admitted 2/14/22). She was initially diagnosed in the hospital with acute on chronic subdural hemorrhage and multiple facial fractures resulting from a fall off of a stair. There is little information regarding the cause of the fall because of patient's confusion upon admission (as well as a previous TBI with unclear impact on the patient's current situation). She underwent burr hole and evacuation surgery for the hemorrhage in late February. The latest imaging studies done in March had indicated the hemorrhage was shrinking in size. The PT/OT notes state ongoing need as patient is functioning below baseline with ADLs.
My initial thought is to use S06.5X9D since she needs rehab for deconditioning and so on; however, I am not sure if this is appropriate given the surgical procedure that was directed at the hemorrhage. There is no more information since March as to how much of the hemorrhage has resolved. All of the follow up Neurosurg notes indicate that she is "recovering well" from surgery. There is also no indication as to if the surgical site still requires wound care (although I sincerely doubt since the procedure was in late February).
Is S06.5X9D an appropriate primary diagnosis for rehab admission to Skilled Nursing Facility?
Thank you, in advance, for your help!
I have a new resident coming in from a long hospital stay (admitted 2/14/22). She was initially diagnosed in the hospital with acute on chronic subdural hemorrhage and multiple facial fractures resulting from a fall off of a stair. There is little information regarding the cause of the fall because of patient's confusion upon admission (as well as a previous TBI with unclear impact on the patient's current situation). She underwent burr hole and evacuation surgery for the hemorrhage in late February. The latest imaging studies done in March had indicated the hemorrhage was shrinking in size. The PT/OT notes state ongoing need as patient is functioning below baseline with ADLs.
My initial thought is to use S06.5X9D since she needs rehab for deconditioning and so on; however, I am not sure if this is appropriate given the surgical procedure that was directed at the hemorrhage. There is no more information since March as to how much of the hemorrhage has resolved. All of the follow up Neurosurg notes indicate that she is "recovering well" from surgery. There is also no indication as to if the surgical site still requires wound care (although I sincerely doubt since the procedure was in late February).
Is S06.5X9D an appropriate primary diagnosis for rehab admission to Skilled Nursing Facility?
Thank you, in advance, for your help!
