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Alex was admitted after suffering from a depressed fracture of the occiput. Lumbar puncture revealed that...

Alex was admitted after suffering from a depressed fracture of the occiput. Lumbar puncture revealed that subdural hemorrhage had results. The depressed fragments were surgically elevated. 1. What 2 CM codes would be used to code this encounter? 2. What additional documentation is needed to completely code case?

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Answer #1

2 CM codes used to code depressed fracture of the occiput are:-

Code SO2.11 is used to code fracture of the occiput

Code SO6.5 is used to code Traumatic Subdural hemorrhage.

Documents needed to code this case completely are:-

1) Discharge summary of the patients

2) All investigation reports like CT or MRI of brain and spine

3) All blood reports

4 ) All procedure done reports of surgery

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