need help coding---neuro
pt had burr hole surg for right subdural hematoma...returned 3 days later to hosp for more drainage of hematoma..returned 1 day later with seizures and left sided weakness...(this was all in the course of 7 days with rehospitalization).....then we got him at home for a homecare admit....help with coding...Is it aftercare neuro surgery? There is after effects..please help
Comments
first place.
Arlene Poolman, RN
Director of Clinical Services
At Home Rehab
800.880.9715
The Professional Care YOU Deserve
weakness were after the burr hole surgery for the drainage of the
hematoma...Do I capture these even though resolved? Do I just code
aftercare? I guess im stumped on this one
The Subdural Hematoma caused by the fall; i.e.: traumatic head injury, is the primary diagnosis. The Burr Holes are the treatment done to relieve the pressure caused by the bleeding from the hematoma. The hematoma and the fall injury did cause damage: the seizures and now the weakness, and maybe more to come as SDH have sequel that can come forth in the near or distant future.
Code the injury as primary, and then code all the symptoms and conditions that have appeared as a result of the injury.
If you have orders for care of the surgical site on the head, then code att’n to surgical dressing. I would not code AC neuro surgery as this is not the focus of your POC. The focus is the injury recovery in my humble opinion.
Nancy Wolverton RN, CCM, HCS-D
Kindred at Home
Little Rock, Arkansas
501-508-8526
Nancy.Wolverton@kindred.com
good job in explaining things J
Arlene Poolman, RN
Director of Clinical Services
At Home Rehab
800.880.9715
*The Professional Care YOU Deserve*
That is how this site works! Ain’t it grand!
Nancy Wolverton RN, CCM, HCS-D
Kindred at Home
Little Rock, Arkansas
501-508-8526
Nancy.Wolverton@kindred.com