Coma, Cleft Palate and Gustilo Classification Documentation

Coma

 

• Document:
    --Somnolence, drowsiness
    --Stupor, catatonic stupor, or semicoma
    --Coma, unconsciousness
    --Include any associated skull fracture or intracranial injury if present
• Document the Glasgow (coma scale) score
    --(Typically reported as a total score 0–15)
    --Higher the score = higher functioning
• Also document each assessment area:
    --Eye opening
    --Verbal response
    --Motor response

Cleft Palate

• Specify palate involvement:
    --Hard
    --Soft
    --Hard with Soft
    --Medial
    --Uvula
• Document cleft lip involvement:
    --Unilateral cleft lip
    --Bilateral cleft lip
    --Median cleft lip
• Document any associated diagnoses/conditions

Gustilo Classification

• Specificity for open fractures of the forearm, femur, and lower leg
will require provider documentation to specify Gustilo Type l through
Type lllC:
    --TYPE l: The wound is smaller than 1 cm, clean, and generally caused by
a fracture fragment that pierces the skin.
    --TYPE II: The wound is longer than 1 cm, not contaminated, and without
major soft tissue damage or defect. This is also a low energy injury.
    --TYPE III: The wound is longer than 1 cm., with significant soft tissue
disruption. The mechanism often involves high-energy trauma, resulting
in a severely unstable fracture with varying degrees of fragmentation.
    --IIIA: The wound has sufficient soft tissue to cover the bone without the
need for local or distant flap coverage.
    --IIIB: Disruption of the soft tissue is extensive, such that local or distant
flap coverage is necessary to cover the bone. The wound may be
contaminated, and serial irrigation and debridement procedures are
necessary to ensure a clean surgical wound.
    --IIIC: Any open fracture associated with an arterial injury that requires
repair is considered IIIC. Involvement of a vascular surgeon is generally
required.
• NOTE: Even though the fracture may be described using the terminology
found in the Gustilo classification the provider must document the type
of Gustilo fracture present; coder CANNOT code based on the fracture
description.