Charlene Posted Tue 12th of March, 2019 17:54:58 PM
Pt fell 8 days s/p L5 laminectomy and developed leg pain radiating pain into left foot, n&v and headache. A dural tear was suspected. At revision of laminectomy, a large amount of hematoma was found with scar down of nerve roots. Complete laminectomy relieved pressure of cord, hematoma was evacuated and nerve roots decompressed. I cannot locate a traumatic dx code that seems to fit the scenario. Hematoma of spinal cord leads to S34125A, and this relates to concussion. There was no head injury. It seems the recent surgery site was traumatized. I find Nerve root injury S34.21XA and S34.22XA and will query surgeon regarding these. Can you locate an appropriate code for the hematoma?
SuperCoder Answered Wed 13th of March, 2019 11:05:39 AM
There is no direct code for injury induced hematoma of the spine during the post-operative period. The closest code that we can relate to is ICD 10 CM code S39.82XA (Other specified injuries of lower back, initial encounter).
Provided ICD 10 CM codes S34.21XA and S34.22XA are specific to nerve root injuries, which is different from our condition vascular injury (Hematoma). Hence these codes cannot be taken.
Hope provided information would be helpful.