AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 2; Ask the Editor

Traumatic Subdural and Subarachnoid Hemorrhage with Loss of Consciousness

A patient with traumatic subarachnoid hemorrhage and traumatic subdural hemorrhage due to a fall was initially noted to have loss of consciousness (LOC), for approximately 30 minutes at the time of injury at home. Upon admission, the patient was awake, alert and oriented, but his neurological status declined and he became unresponsive and comatose for over 24 hours without regaining consciousness. He was discharged to a long-term care hospital for continued care. What seventh character is assigned for the LOC (e.g., the initial LOC at the time of the injury or the longest duration)? Additionally, what is the appropriate present on admission indicator (POA) for the traumatic brain hemorrhages with LOC? ...

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