Understanding Medical Coding of Cerebral Edema

A common misconception among coders is that cerebral edema is merely a symptom of another condition and therefore cannot be coded independently. However, this is not true. Cerebral edema is a significant condition in its own right. As long as there is clinical documentation and treatment/monitoring supporting a diagnosis of cerebral edema, it can and should be coded.

Conditions That Precipitate Cerebral Edema

Cerebral edema often accompanies or is precipitated by other serious diagnoses that cause brain swelling, such as:

• Traumatic brain injury (TBI)
• Ischemic stroke
• Hemorrhagic stroke
• Infections, including: Meningitis, Encephalitis, Toxoplasmosis
• Subdural abscess (empyema)
• Tumors
• High altitude sickness

Impact of a Cerebral Edema Diagnosis on MS-DRG

Cerebral edema is classified as a major complication or comorbidity (MCC). Properly capturing this diagnosis is crucial as it ensures that the claim submitted for reimbursement accurately reflects the resources expended to treat the patient.

Consider the following comparison to understand its impact on MS-DRG:

• MS-DRG 024: Craniotomy with Major Device Implant or Acute Complex CNS PDX without MCC
  • Relative Weight: 3.7888
  • Reimbursement: $24,618.75
• MS-DRG 023: Craniotomy with Major Device Implant or Acute Complex CNS PDX with MCC or Chemotherapy Implant or Epilepsy with Neurostimulator
  • Relative Weight: 5.688
  • Reimbursement: $36,834.56

What if Cerebral Edema is Not Specifically Documented?

If clinical indicators for cerebral edema are present in the record, particularly in the setting of an often-related serious diagnosis, but cerebral edema is not explicitly documented, the coder should pose a query for clarification.

According to the AHIMA and ACDIS’ joint publication, "Guidelines to Achieving a Compliant Query Practice," clinical indicators are:

“…documentation that supports a diagnosis as reportable and/or establishes the presence of a condition. Examples of clinical indicators include (but are not limited to): provider observations (physical exam and assessment), diagnostic tests, treatments, medications, trends, and consultant documentation authored by providers and ancillary professionals documented throughout the health record.”

Clinical indicators of cerebral edema include the following:

• Symptoms:
  • Headache
  • Neck pain or stiffness
  • Nausea or vomiting
  • Dizziness
  • Irregular breathing
  • Vision loss or changes
  • Memory loss
  • Inability to walk
  • Difficulty speaking
  • Stupor Seizures
  • Loss of consciousness
• Diagnostic Tests:
  • Physical exam of head, neck, and nervous system
  • Radiologic exams (CT/MRI)
  • Blood tests
• Treatment:
  • Oxygen therapy
  • IV fluids
  • Lowering body temperature (hypothermia)
• Medications, including:
  • Decadron (Dexamethasone)
  • Mannitol
  • Osmitrol
  • Solu-Medrol
  • Depo-Medrol
  • Kenalog
  • Cortef
  • MethylPREDNISolone
  • Betamethasone
  • Ventriculostomy
• Surgery, including:
  • Craniectomy to relieve intracranial pressure
  • Procedures to address the source of the swelling

Takeaways

Cerebral edema is a clinically significant diagnosis often found to be precipitated by other serious conditions. Designated as an MCC, its assignment as a secondary diagnosis can substantially impact the relative weight of the DRG for an inpatient admission. Numerous clinical indicators suggestive of cerebral edema, when documented in the health record without an accompanying diagnosis of cerebral edema, should prompt the coder to query the provider to determine whether assignment of a code for cerebral edema is appropriate.

For more detailed information about coding for cerebral edema, including discussions of specific types of cerebral edema, diagnoses that are not cerebral edema, sample queries, and additional resources, take the HIAlearn course, "Cerebral Edema Overview: Types, Causes, Diagnosis, Treatment, and Coding."

References

HIALearn Cerebral Edema Overview: Types, Causes, Diagnosis, Treatment and Coding
AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice
WebMD Medications for Cerebral Edema
Cerebral Edema (Brain Swelling): Symptoms, Causes, & Treatment (webmd.com)

About our Cerebral Edema Overview: Types, Causes, Diagnosis, Treatment and Coding Course

In this course, participants will gain invaluable insights into the various facets of cerebral edema. The curriculum meticulously covers its causes and types, delving deep into its pathophysiology, symptoms, diagnosis, and the array of available treatments. Armed with this enhanced understanding, coders will be adept at meticulously reviewing medical records. This proficiency will empower them to assign accurate codes to diagnoses related to cerebral edema, ultimately boosting their coding productivity and precision.

The information contained in this blog post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.