Cerebral Edema

sabullock

Is cerebral edema considered an intergral part of a SDH/ICH or other traumatic head injuries. Or is it a seperate diagnosis to be coded. If there is a Coding Clinic or other reference that supports this please provide.

nbrunson84

It's a code I try to include as it is a MCC. I will Query for it if I
find it in Radiology.

Here's the Coding Clinic:

AHA Coding Clinic for ICD-9-CM, 3Q 2009, Volume 26, Number 3, Page 8

Question:

The patient is a 48-year-old male with glioblastoma multiforme status
post two surgeries. The tumor has recurred with massive growth since
debulking one month ago. The provider indicated that there was a
significant amount of surrounding vasogenic edema and mass effect. Is it
appropriate to assign a code for cerebral edema when it is due to a
primary intracranial process such as a brain tumor and the provider has
indicated that it is clinically significant?

Answer:

Assign code 348.5, Cerebral edema, as an additional diagnosis, since the
provider has evaluated and documented the clinical significance of the
vasogenic edema.

Patients with glioblastoma commonly develop vasogenic edema. Vasogenic
edema is an accumulation of fluid in the brain (due to the tumor's
disruption of the blood-brain barrier). The surrounding edema can
increase the mass effect of the tumor and is considered an irreversible
process. Tumor-related vasogenic edema may disrupt synaptic transmission
and alter neuronal excitability, leading to headaches, seizures, focal
neurological deficits, and encephalopathy. The condition can contribute
to morbidity, resulting in fatal brain herniation.



N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center

sabullock

Thanks - we have been but were recently told be a coder this was integral part of the diagnosis and as such included.

fosterma

Not every patient with a SDH/ICH or tumor gets cerebral edema / vasogenic edema. We query for the diagnosis and it is coded separately if the physician documents it in a progress note. There are not ICD-9 exclusion codes under Cerebral Edema [348.5] so I do not believe it is considered and "intregal" part of the diagnosis. Hope this helps..

bea.smith

Speaking along these same terms, do any of you add ascites as a
secondary dx on patients with end stage liver disease/ cirrhosis? I have
recently been told I can pick that up, but I am still a little
undecided.

mannb1

Yes, I always use ascites as CC if MD documents it. I haven't been told by my coders that it's not useable with ESLD/cirrhosis.

Becky Mann, RN, CDS
Clinical Documentation Improvement
Health Information Services
becky.mann@stjoe.org
707-337-3779, ext. 3593

testes

It is included in trauma cases....I will try and find the coding clinic
as it pertains to trauma, I was reading it the other day....


Thank you,
Tiffany

So let it be written, So let it be done.

testes

Ok, I have had lunch and my brain is functioning.....

You can code cerebral edema separately however it cannot be coded strictly from the radiology report. It must meet the definition of reportable secondary diagnosis outlined in the uniform hospital discharge data set.

For UHDDS reporting purposes, the definition of "other diagnosis" includes only those conditions that affect the episode of hospital care in terms of any of the following:

cynthia.a.goewey

Here is one I used this week...
I am following the stay of Mr. X. I see he was transferred here with a diagnosis of a new brain tumor. I see the radiology report of his head MRI demonstrated a 4.8 cm inhomogeneously enhancing L occipital mass with significant edema and local mass effect to occipital horn of L lateral ventricle. I see he was started on decadron and will be going to the OR this week. If any of the following are appropriate to further describe the results of his radiology report and they are clinically significant for the pt would you please place in your progress notes:

a) Cerebral edema

b) Vasogenic edema

c) Compression of the brain

d) Other
Cindy

paxneros

What a timely question! I too wa having to query for this diagnosis.

I worded my query to incorporate the findings of the Brain CT showing the Edema and then gave the treatment plan - Steroids and insertion of ICP monitor.

I then ask the doc to make sure "all valid diagnoses were documented for Medical Necessity" and left it at that.

I wanted to leave choices but didn't know which to include @ that time. I like your query choices and will incorporate them iinto my own!

NBrunson, RHIA, CCDS

dbutler

Very nicely done.

A few observations on the wording of the query --
*I like very much that you specifically asked for 'clinically
significant' diagnosis.
*The second point, all of the options you've presented are at the MCC
level, would likely be better from a compliance viewpoint to include at
least one that is not an MCC (but can't come up with a clinically
reasonable option right now).
*Finally, consider adding the default "clinically indeterminable" or
"uanble to determine" as a final choice -- used in the AHIMA Query
Practice brief and specifically called for:

"Multiple choice formats that employ checkboxes may be used as long as
all clinically reasonable choices
are listed, regardless of the impact on reimbursement or quality
reporting. The choices should also
include an “other” option, with a line that allows the provider to
add free text. Providers should also be
given the choice of “unable to determine.” This format is designed
to make multiple choice questions as
open ended as possible."

Don

cmorell

In keeping with the lessons learned at National ACDIS, I would follow the building blocks of queries and write:

Per the MRI- noted was "a 4.8 cm inhomogeneously enhancing L occipital mass with significant edema and local mass effect to occipital horn of L lateral ventricle." If possible, please further specify the type of documented edema necessitating IV Decadron.
(e.g. Vasogenic edema,Cytotoxic edema,Osmotic edema,Hydrostatic edema,Interstitial edema,or other more appropriate diagnosis.)
Then I would have boxes for no additional information available and unable to determine.

In my research, these are the only types of edema I could locate and edema is already documented so you are just asking for more specificity.

cynthia.a.goewey

I like the way you worded this. I will keep it in my files and use next time I am querying for cerebral edema.
Thanks,
Cindy

paxneros

Very nicely worded!! Good job!

~Norma

heidi.koenig

Thanks everyone!

Heidi Koenig, RN
Clinical Document Specialist
Ocala Regional Medical Center
Heidi.koenig@hcahealthcare.com
352-401-1686

Unknown

Great replies!

dvitalone1

I just want to say that I have been a nurse for over 18yrs and have wore a lot of hats. Being part of the ACDIS team and being in a career with such professional, kind and helpful people is very rewarding and I want to thank all of you for that!