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.
Cerebral edema often accompanies or is precipitated by other serious diagnoses that cause brain swelling, such as:
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.
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.”
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)
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.
HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for over 30 years—offers a comprehensive online education platform for medical coders. With a catalog of over 200 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection accredited by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPT, E/M, ICD-10-CM, ICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatient, outpatient, profee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CM, ICD-10-PCS, CPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams. With over 1,600 users already part of the HIAlearn community, the platform stands as a testament to its commitment to providing quality education and support for medical coders nationwide.
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.