No, I wouldn’t pick up substance abuse. While he does have the abstinence syndrome, it wasn’t his direct use/abuse of substance.
Based on the information provided, I believe this patient would meet the isolated hip fracture exclusion and NOT be captured as PTOS. In Appendix 15 of the PTOS Manual there are examples provided. This scenario seems similar to Fall from standing (knocked over/pushed) with an isolated hip fracture, which is non-PTOS. However, if a horse […]
You don’t need the term “TBI” if you have a specific diagnosis of brain, skull or scalp injury (can be open or closed) , as long as it caused anything from drowsiness to an intracranial bleed. So just diagnosis of SAH is fine; if you get into milder skull/scalp injury I would want to see […]
Can you please clarify the pre-existing history of head trauma? The term TBI doesn’t need to be specifically documented, correct? If we have documentation of SAH, SDH, concussion, etc. is that sufficient? What about closed head injury?
This scenario falls under W01.0 (tripping over animal). W01.0 does fall within the accepted code range for our solitary hip fracture exclusion. Therefore, based on the information provided, this patient would meet the exclusion and would NOT be captured as PTOS.