trauma room

Would this scenario be included for PTOS? The patient came in after being “bumped” by a horse after it was startled causing fall to ground resulting in an Isolated Femur Fx.

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 […]

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?

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 […]

We were having a discussion about an isolated hip fracture and are unsure if she should be included as we feel she falls in a sort of grey area. She was attempting to take her dog out for a walk and in his excitement he tripped by going under her feet and she fell from standing. Not sure is she should be PTOS or not. Should her mechanism be FFS or contact with dog? Please let us know what you think.

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.