Cerebral Edema Query?

ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
edited April 2016 in CDI Talk Archive
Does anyone have a cerebral edema query they would be willing to share with me?
Thanks!
Greta


Greta Goodman, CCDS
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com

Comments

  • Unknown
    edited April 2016
    Here is a wording example:
    In this 74 year old admitted with confusion encephalopathy could you render your opinion as to the clinical significance of the abnormal CT scan? i.e. not clinically significant, cerebral edema, other more appropriate diagnosis
    Clinical indicators:
    There is vasogenic edema in left frontal lobe with mild mass effect
    2.2 cm mass. . .significant surrounding edema with associated mass effect
    Progressive confusion. . .CT head. . .left frontal lobe swelling. MRI 2 cm mass

    01/15 CT head
    01/15 MRI brain
    01/16 Dr. W consult




    Charlene Thiry RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Quality Resources
    Menorah Medical Center
    5721 W. 119th Street | Overland Park, Kansas 66209
    Charlene.Thiry@hcahealthcare.com
    Mobile: 913-498-6388
    www.menorahmedicalcenter.com

  • katysuegood@gmail.comkatysuegood@gmail.com
    We have two way we do it. We either use our specific cerebral edema/brain compression query or I use our non-treating provider query with the radiology findings. Either works.

    Cerebral edema/compression:

    The medical record indicates the following;
    Diagnosis of: _____________________________________________________________________________
    Study performed: __________________________________________________________________________
    Radiologist describes: ______________________________________________________________________
    Glasgow Coma Scale/ Description of Mental Status:_______________________________________________
    Other: ___________________________________________________________________________________

    The patient condition necessitated;
    • Neuro Consult
    • Surgical Evacuation
    • ICP Monitor
    • IV Steroids (Mannitol, Osmitrol, etc)
    • Other ___________________________________________

    Please indicate if one (or more) of the following accurately describe any associated additional diagnoses for this patient:
  • kerryseekircherkerryseekircher
    edited April 2016
    Katy-
    I love the edema/compression query.
    Thank you for sharing.
    Kerry


    Kerry Seekircher, RN, CCDS, CDIP
    Documentation Specialist Supervisor
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    You’re welcome ☺

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • hryfinskihryfinski
    edited April 2016
    Here is a copy of our cerebral edema query template. We have a lot of trauma and neuro cases at our hospital. We were finding the use of "mass effect" and "brain swelling" often. Education to our providers re: coding guidelines and terminology was VERY helpful in getting the "cerebral edema" documentation we need. Education on the fact that we are unable to code from imaging reports was also helpful.

    PT Name: ***
    Acct #: ***
    MR #: ***
    Admit date: ***

    PROVIDER DOCUMENTATION REQUEST

    Dear Dr:***
    Date: 5/28/14

    Please review the following and provide your response in the progress notes:

    Clinical Indicators:
    *** (Include radiologic findings and any meds given for cerebral edema)

    Please specify and document in the medical record if the patient is being monitored, treated and/or evaluated for. Please document all that apply

    -Cerebral Edema
    -Vasogenic Edema
    -Radiologic finding, clinically insignificant
    -Other
    -Unable to determine

    Use of terms such as suspected, possible or probable (associated with a specific diagnosis that is being evaluated, monitored or treated as if it exists) are acceptable and can be coded in the inpatient setting.

    If you have any questions on the above, please contact *** at extension ***

    Thank you ,
    Hailey Ryfinski RN

    Please use your independent medical judgement in providing your response.
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