Annette Posted Thu 15th of April, 2010 01:17:38 AM
what diagnosis can I use for
"status post anterior cervical discectomy fusion with expanding hematoma of neck"?
SuperCoder Answered Thu 15th of April, 2010 08:34:42 AM
There is no specific code for expanding hematoma so you need to code 920 only.
SuperCoder Answered Thu 15th of April, 2010 09:11:40 AM
If the current hematoma is not linked with the previously done ACDF surgery, then code as this -- code 920 as the primary Dx, and you can also code V45.4 as secondary Dx, to indicate the "status ACDF" condition.
If the current "expanding hematoma of neck" is documented as a complication developed after the ACDF surgery and linked to the ACDF, then code 998.12 as the primary code and V45.4 as the secondary dx.
Annette Posted Thu 15th of April, 2010 14:32:37 PM
Well the fusion was on 1/26/10 & the evacuation for the hematoma was on 1/27/10
brief history states:
Patient admitted status post anterior cervical discectomy fusion on 1/26 with expanding neck.. I explained to the patient that he likely has bleeding and we should return to the operating room for decompression and for hemostasis in order to avoid respiratory complications.
SuperCoder Answered Thu 15th of April, 2010 16:39:15 PM
In this case, as I said earlier, primary Dx will be 998.12, and secondary Dx will be V45.4.
Annette Posted Thu 15th of April, 2010 17:54:16 PM
thank you so much for your help