Diagnoses Archives

I am a little confused on the rule of do not use code Y92.9 if the place is not stated or is not applicable. I’ve had a number of charts that have no place of occurrence given on where the injury occurred. What would you suggest we use in these instances?

That is an odd guideline, right, because the code itself is the unspecified location. What ICD-10 is looking for, is that someone has documented, place of injury unknown (or unspecified), …

Continue reading “I am a little confused on the rule of do not use code Y92.9 if the place is not stated or is not applicable. I’ve had a number of charts that have no place of occurrence given on where the injury occurred. What would you suggest we use in these instances?”

How should a retroperitoneal hematoma be coded? I am unable to use K codes (that my encoder selected for me) in the registry, so I want to be sure I am selecting the correct alternative code or is it okay to leave ICD blank and just code AIS. Thank you for your guidance.

When you look in the index for ICD-10, there is a code for non-traumatic, and one code for traumatic. We would use the traumatic code. S36.892A Hematoma – retroperitoneal (nontraumatic) …

Continue reading “How should a retroperitoneal hematoma be coded? I am unable to use K codes (that my encoder selected for me) in the registry, so I want to be sure I am selecting the correct alternative code or is it okay to leave ICD blank and just code AIS. Thank you for your guidance.”

I just want to clarify a few questions we have when using hypothermia as a diagnosis. In the guidelines it’s documented as a rectal or core temperature <= 34o C or 93.2 o F.. If the patient presents it’s considered a dx but if unexpected capture as a hospital event. First, If a patient comes in with a temperature of 35 degrees Celsius on admission are we to be coding this as a diagnosis, as it’s an injury in the AIS book that would give you an ISS score? Second, In the below clarification from AAAM it states to not round up or down for a temperature. If a patient has a temperature of 34.7 Celsius on admission is this then a diagnosis or does the temperature have to be 34 or less? What about picking it up as a hospital event 34 or less or can we pickup if the patient has a temperature of 34.2?

Hypothermia that is present on arrival and not related to treatment or sequela is coded. You would capture this as 34 degrees since you are not rounding up or down. …

Continue reading “I just want to clarify a few questions we have when using hypothermia as a diagnosis. In the guidelines it’s documented as a rectal or core temperature <= 34o C or 93.2 o F.. If the patient presents it’s considered a dx but if unexpected capture as a hospital event. First, If a patient comes in with a temperature of 35 degrees Celsius on admission are we to be coding this as a diagnosis, as it’s an injury in the AIS book that would give you an ISS score? Second, In the below clarification from AAAM it states to not round up or down for a temperature. If a patient has a temperature of 34.7 Celsius on admission is this then a diagnosis or does the temperature have to be 34 or less? What about picking it up as a hospital event 34 or less or can we pickup if the patient has a temperature of 34.2? “

I have a unique situation with an open fx. I have a 7 year old who was playing with his brother with a golf club and was hit in the face. He is a tx from another facility and seen in our ED and discharged home from the ed. He has a left mandibular body fx that is comminuted displaced and open. He also has a left lower jaw laceration 2.0 cm and an intraoral mucosal lac 0.5 cm. Plastic surgery repairs both lacs and he is sent home. My question is do I pick up the lacerations in the dx or not because they are considered part of the open fx? This would make it that I am having two laceration repairs and irrigations without a laceration dx in the procedure section. Is it just assumed that they are both from the open fx? Any help in this matter is greatly appreciated.

You won’t code separately any laceration that is part of the open fracture, with the wound and fracture communicating. You should go ahead and code the procedures, yes, it is …

Continue reading “I have a unique situation with an open fx. I have a 7 year old who was playing with his brother with a golf club and was hit in the face. He is a tx from another facility and seen in our ED and discharged home from the ed. He has a left mandibular body fx that is comminuted displaced and open. He also has a left lower jaw laceration 2.0 cm and an intraoral mucosal lac 0.5 cm. Plastic surgery repairs both lacs and he is sent home. My question is do I pick up the lacerations in the dx or not because they are considered part of the open fx? This would make it that I am having two laceration repairs and irrigations without a laceration dx in the procedure section. Is it just assumed that they are both from the open fx? Any help in this matter is greatly appreciated.”

Please help me understand what timeframe I should be looking for brain injuries for this case. This patient was a GSW to the face/head. He went urgently to the OR for treatment of his facial injuries, but the head injuries (no mention of herniation at this time) didn’t need treatment at that time. While in the ED before he went urgently to the OR, he had an EVD placed. The next morning, he was again taken emergently to the OR for treatment of herniation of brain tissue through the existing orbital injury. This all occurred within 24 hours of the injury. Would I include the “herniation” in his injuries being that this happened within 24 hours of his injury, or would I exclude because he had already been to the OR (not for head injuries) and/or would I exclude because he had already had an EVD placed in the ED. I guess in other words, am I able to include size, herniation, etc. that happened within 24 hours of the injury, even if the patient already went to the OR or already had an EVD placed?

The 24 hour rule applies to capture size of the injury, as close to or after 24 hours, to capture the “full” size of the injury. If you have an …

Continue reading “Please help me understand what timeframe I should be looking for brain injuries for this case. This patient was a GSW to the face/head. He went urgently to the OR for treatment of his facial injuries, but the head injuries (no mention of herniation at this time) didn’t need treatment at that time. While in the ED before he went urgently to the OR, he had an EVD placed. The next morning, he was again taken emergently to the OR for treatment of herniation of brain tissue through the existing orbital injury. This all occurred within 24 hours of the injury. Would I include the “herniation” in his injuries being that this happened within 24 hours of his injury, or would I exclude because he had already been to the OR (not for head injuries) and/or would I exclude because he had already had an EVD placed in the ED. I guess in other words, am I able to include size, herniation, etc. that happened within 24 hours of the injury, even if the patient already went to the OR or already had an EVD placed?”

Can we code osteophyte fractures?

Pathologic, chronic, age-indeterminate, stress, and traumatic fractures are all coded differently in ICD-10; only traumatic codes are included within the PTOS inclusion criteria.AIS has clarified that osteophyte/bone spurs are not …

Continue reading “Can we code osteophyte fractures?”

As you know for the hypothermia hospital event, the temperature is defined as < 34 C or 93.2 F. Does this also apply to the diagnosis or may we pick it up per AIS score at 35 C?

If it is present on arrival, for the purposes of diagnoses, you can enter up to 35 c. You are correct that this is different from the hospital event definition.

I have a prosthetic hip dislocation (T84.02) with a traumatic mechanism, over reached for something and fell. Like our peri-prosthetic fractures, am I coding this to hip dislocation (S73.0) and including as PTOS?

The S73 code has an Excludes 2 note, excluding dislocation of prosthetic. So if all that is dislocated is the prosthetic, it directs to use the T84 code, which does …

Continue reading “I have a prosthetic hip dislocation (T84.02) with a traumatic mechanism, over reached for something and fell. Like our peri-prosthetic fractures, am I coding this to hip dislocation (S73.0) and including as PTOS?”

I have a patient that on her initial imagining did not show a brainstem herniation. On a follow up one, it was present. The follow up one that it was on, was greater than 24 hours. In the AIS book, it states that coding of brain injuries should be done at 24 hours or initial confirmed diagnosis is later than 24 hours. Would this herniation be able to be included in the injuries??

The guideline states, “coding of brain injuries should be done at 24 hours or at initial confirmed diagnosis if later than 24 hours.” Since the initial brainstem herniation was not …

Continue reading “I have a patient that on her initial imagining did not show a brainstem herniation. On a follow up one, it was present. The follow up one that it was on, was greater than 24 hours. In the AIS book, it states that coding of brain injuries should be done at 24 hours or initial confirmed diagnosis is later than 24 hours. Would this herniation be able to be included in the injuries??”

Are we reading the manual correct that if a head bleed is noted on the first CT the registry is to code the size of the head bleed within the first 24 hours. If the head bleed is noted anytime after the first 24 hours that would be considered the initial confirmed diagnosis and the registrar is to capture the injury?

Correct. You are to code brain injuries based on what is documented closest to or at 24 hours, or at initial confirmed diagnosis if later than 24 hours. If a …

Continue reading “Are we reading the manual correct that if a head bleed is noted on the first CT the registry is to code the size of the head bleed within the first 24 hours. If the head bleed is noted anytime after the first 24 hours that would be considered the initial confirmed diagnosis and the registrar is to capture the injury?”