I'm sure the coders here know the right answer, but I'd probably go with 780.61, fever presenting with conditions classified elsewhere, and then choose the underlying cause (ICH, etc.).
I see a code for "cerebral fever" 323.9 and "cerebral late effect" 326 which discusses late effects of intracranial abscess or pyogenic infection. I would ask the provider to clarify and you may get something.
Of course the coders here will know a lot more about this than I do. I will defer to their expertise.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
Your response raises a question for me. As a clinician, I wouldn't think of hypothalamus and cerebral as the same process, because clearly the hypothalamus is not located in the cerebrum. Except for where it's specified further, is "cerebral" coder-speak for brain, regardless of actual part of the brain?
Renee
Linda Renee Brown, RN, CCRN, CCDS Certified Clinical Documentation Specialist Banner Good Samaritan Medical Center
Good questions and I don't think I have a good answer.
-323.9 states (in my trusty ICD-9 manual) "Unspecified cause of encephalitis, myelitis, and encephalomyelitis." -326 states "Late effects of intracranial abscess or pyogenic infection. Note: This category is to be used to indicate conditions whose primary classification is to 320-325 [excluding 320.7321.0,-321.8, 323.01-323.42, 323.6-323.7] as the cause of late effects, themselves classifiable elsewhere. The "late effects" include conditions specified as such, or as sequela, which may occur at any time after the resolution of the causal condition. Use additional code to identify condition, as: Hydrocephalus (331.4) Paralysis (342.0-342.9, 344.0-344.9)"
This may not be much help. Again, I have to defer to the expertise of the coders here.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
I just had another thought. Does the patient meet the criteria for SIRS? That requires 2 of 4 symptoms (temperature being one) and doesn't require a source of infection.
Robert
Robert S. Hodges, BSN, MSN, RN Clinical Documentation Improvement Specialist Aleda E. Lutz VAMC Mail Code 136 1500 Weiss Street Saginaw MI 48602
Comments
Renee
Linda Renée Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Of course the coders here will know a lot more about this than I do. I will defer to their expertise.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
Your response raises a question for me. As a clinician, I wouldn't think of hypothalamus and cerebral as the same process, because clearly the hypothalamus is not located in the cerebrum. Except for where it's specified further, is "cerebral" coder-speak for brain, regardless of actual part of the brain?
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Good questions and I don't think I have a good answer.
-323.9 states (in my trusty ICD-9 manual) "Unspecified cause of encephalitis, myelitis, and encephalomyelitis."
-326 states "Late effects of intracranial abscess or pyogenic infection. Note: This category is to be used to indicate conditions whose primary classification is to 320-325 [excluding 320.7321.0,-321.8, 323.01-323.42, 323.6-323.7] as the cause of late effects, themselves classifiable elsewhere. The "late effects" include conditions specified as such, or as sequela, which may occur at any time after the resolution of the causal condition. Use additional code to identify condition, as: Hydrocephalus (331.4) Paralysis (342.0-342.9, 344.0-344.9)"
This may not be much help. Again, I have to defer to the expertise of the coders here.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov