A: Hypothermia is coded if it is a result of the primary injury, not treatment related or sequel of treatment. The temperature should be taken at your facility and be a core temperature – we would say you don’t qualify for “Hypothermia” unless the environmental temperature is low and causes chilling that requires additional treatment beyond normal measures taken in the trauma room to preserve normothermia. It is also good to have the MD note it as a co-morbidity or part of the patients issue to address. You will have to use your best judgement to assure the patient really has hypothermia. If the patient is transferred, the hypothermia would be captured just like you would capture any other injury (i.e. fractured femur) that was diagnosed at the referring hospital – as long as it fits the criteria.
