Wiki Subdural Hemorrhage

[tharal]

Hi,

I need a coding help!

Patient arrived after a fall. Has a history of traumatic subdural hemorhage (before one month).
Evaluated and find out the reason for fall is that chronic subdural hemorrhage. In the previous visit nothing done for that SDH because the patient is not ready to do any surgery or draining for SDH. So the SDH is still there. Can we code the chronic subdural hemorrhage as traumatic since it's the same one in the history (traumatic SDH)?

Thanks in advance for any help...

Thara L CPC H

 

[balakrishnanv]

Hi,

This is cannot be coded as traumatic, it should be coded as pathological if its being treated currently else just a Hx code would go.

Thanks,

Bala.

 

[mitchellde]

Hi,

I need a coding help!

Patient arrived after a fall. Has a history of traumatic subdural hemorhage (before one month).
Evaluated and find out the reason for fall is that chronic subdural hemorrhage. In the previous visit nothing done for that SDH because the patient is not ready to do any surgery or draining for SDH. So the SDH is still there. Can we code the chronic subdural hemorrhage as traumatic since it's the same one in the history (traumatic SDH)?

Thanks in advance for any help...

Thara L CPC H

I am a little confused.. was the trauma the fall that caused a head injury which then resulted in the subdural hemorrhage? Or does the patient have a subdural hemorrhage that caused this current fall? What was the original trauma then, was it a closed head injury? There are too many different answers without some clarification, but this is not pathologic and apparently not a history of situation. With some addition information I can be of better assistance.

 

[tharal]

Its documeted as due to that SDH patient fell, and in current impression its saying Chronic SDH.
In previous visit its documented as SDH after fall. In the current encounter throughout the record its saying chronic SDH and the physician saying the current fall may be due to lack of treatment for SDH in the previous visit. I am also totally confusing about this scenrio.

Thank you Debra for your time...

Thara L CPC H