Hello, I would greatly appreciate your expertise in the following scenario that leads to the general question ‘Do we code the condition as it still exists or a history of the condition when MD write Progress Notes during multiple subsequent visits and the surgery was already done on day #1?"
Example, A/P day 3 etc "Female with SAH (hemorrhage) on 3/10 due to Right PCoA aneurysm, s/post balloon-assisted coiling on 3/11. Vasospasm treated with IA Verapamil 3/15, 3/18. Stable neuro exam
– Vasospasm watch
– TCD today
-Plan for cerebral Ag Thursday
-Following"
Do we still code I60.31- aneurysm w/hemorrhage and Z98.890- post procedural state even though it’s been operated and no hemorrhage exists OR we code History of hemorrhage + Z98.890?
Thank you very much.