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July 6, 2022

We have a patient with pneumocephalus but no skull fracture. We believe the pneumocephalus is due to his  Lefort 2 fracture. Is sequential neurologic documentation required for this patient?

First, I want to remind you that the sequential neurological documentation data element is optional and is no longer submitted to the central site. Centers now have the liberty to abstract this data element as they see fit for their institution, or not at all. In other words, this data element is a facility-specific data element, and is no longer part of the PTOS dataset.

If you would like to abstract this data element based on the definition that was applicable 2021 and prior, it does look like pneumocephalus is coded to the head region in AIS. Therefore, 1 (yes) or 2 (no) should be recorded for the sequential neuro data element. Option 3 for head or spine injury not present would not apply. I don’t see anything in the AIS coding guidelines that states pneumocephalus should not be coded in addition to a Lefort fracture.

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