March 15, 2024
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 injury that isn’t identified in the first 24 hours, you would code it when it is identified. However, this does not include anything due to the treatment. So if size is impacted by treatment, go with the size prior to treatment, but any new injuries, not related to the treatment, would get picked up.
Can't find an answer to your question? No problem simply submit your question via email.