Trauma Talk Question 1:
“When the ED Disposition is TRANS and the Outcome is ALIVE, do you
need to go back and change the outcome if they died at the facility
where they were transferred to?”
Trauma Talk Answer 1:
“The
answer to your question is "No". The Outcome field indicates the
patient's final outcome at your facility only. If your
registry wants to keep track of transferred patients who ultimately
died at the facility that they were transferred to, then I would
record or enter that information in the "QI/PI Issues" section of
TraumaBase.”
*Answer submitted by Erika
O’Neal, RHIT, CSTR
AOTR CODING SURVEY #1
24
respondents
How do you code Cerebral Edema, traumatic?
One of the brain’s responses to trauma is Cerebral Edema, an excessive
accumulation of water within the brain, which can cause the brain to
swell and increase intracranial pressure (ICP). Cerebral edema is not
a direct injury to the brain, but rather, a symptom or sequela of a
traumatic brain injury.
How
do you code Pneumocephalus, traumatic?
Pneumocephalus is the presence of air or gas within the skull.
Fractures of the face, the basilar skull, the paranasal sinuses, and
the sella turcica are typical injury sites, which can result in
pneumocephalus. Pneumocephalus can also be a result of open skull
fractures. Pneumocephalus is not a direct injury to the head, but
rather, a symptom or sequela of a traumatic head injury.
How do you code Cerebral Shear Injuries?
Cerebral shear injury results when the brain bounces back and forth
against the wall of the skull when it is subjected to acceleration /
deceleration forces (i.e. whiplash, head hits the windshield, shaken
baby syndrome). Shear injury occurs at a cellular or microscopic level
and causes the brain’s axons (large nerve fibers) and blood vessels to
shear or stretch. When the blood vessels stretch, small petechial
hemorrhages may occur. Diffuse axonal injury (DAI) is a cerebral shear
injury that causes widespread damage to axons and has several degrees
of severity (mild, moderate, severe). DAI typically causes deep coma
of six hours or greater and is often associated with severe cerebral
edema and intracranial pressure (ICP) elevation.
**16 answered question; 8 skipped question; 2 indicated that they
needed more information
Would
you code the patient with an injury?
Scenario 1:
Patient is discharged with a final diagnosis of "fractured arm" and
sent home in a sling or cast, but the x-rays have been read as a
"negative" by the radiologist.
Comments:
1.
I would follow up w/TPM. Although you should use films, the cast/sling
would be a flag for injury.
2.
Does the attending MD written note in the progress notes carry more or
less weight than a consultation note from the radiologist?
3.
A mechanism of injury would need to be
mentioned and I would look for an ortho dictation to determine an
injury from their expertise.
4.
Only if specialist states there is a fx, clinical fx or similar.
5.
Probably not - especially if patient was discharged from the ER.
6.
No, unless the ortho consult sheet or dictation says there is a
fracture, then yes.
7.
WE CODE REGIONS OTHER THAN BRAIN BASED UPON CLINICAL DOCUMENTATION IN
ADDITION TO OR IN LIEU OF RADIOLOGIST FINDING.
8.
Yes, with a NFS ICD 9.
9.
If dx was documented by physician in notes, then yes, otherwise no
(this scenario unlikely at my facility).
10.
Based upon clinical correlation.
Scenario 2:
Patient is
discharged with a final diagnosis of a "cerebral contusion" or a "skull
fracture", but the CT or MRI has been read as "negative"
by the radiologist.
** 5 skipped the question
Comments:
1.
I would first check the neurosurgeon's
dictation and check for mechanism of injury.
2.
Only if specialist states same.
3.
No, unless the nuerosurg consult sheet or dictation states otherwise,
then yes.
4.
BRAIN INJURIES ARE NOT CODED ON CLINICAL DIAGNOSIS ALONE.
5.
If dx was documented by physician in notes, then yes, otherwise no
(this scenario unlikely at my facility).
6.
Based upon clinical correlation.
7.
Depends on the notes in the chart and who documented what.
Scenario 3:
The physician progress
notes state that the patient has a "fracture" or an "internal injury",
but all radiology films are read as negative by the radiologist.
**5 skipped the question
Comments:
1.
Unless proven by surgery.
2.
I would need to know the specialty of the physician who wrote the
progress notes and check for mechanism of injury.
3.
Only if specialist states.
4.
I have done this, wondered about it at the time, but I did code it.
5.
WE CODE OTHER BODY REGION INJURIES BASED ON CLINICAL FINDINGS IN
ADDITION TO OR IN LUEI OF RADIOLOGIST VERIFICATION.
6.
Yes, for fx; internal injury would require more research of
documentation.
7.
Based upon clinical correlation.
8.
Depends on the notes in the chart and who documented what.
9.
Again, when conflicting stories, I follow up with the RN's.
