CDI Adult MDC 1 - Neurology

Question 1

Cervical Cord

Answer 1

The first and second cervical segments are what holds the head.

The cervical cord innervates the deltoids (C4), biceps (C4-5), wrist extensors (C6), triceps (C7), wrist extensors (C8), and hand muscles (C8-T1)

Question 2

Thoracic Cord

Answer 2

The thoracic vertebral segments are defined by those that have a rib. The spinal roots from the intercostal (between the ribs) nerves that run on the bottom side of the ribs, and these nerves control the intercostal muscles and associated dermastomes

Question 3

Lumbosacral Cord

Answer 3

The lumbosacral vertebra forms the remainder of the segments below the vertebrae of the thorax. The lumbosacral spinal cord, however, starts at about T9 and continues only to L2. It contains most of the segments that innervate the hip and legs, as well as the buttocks and anal regions.

Question 4

Cauda Equina

Answer 4

The spinal cord ends at L2 vertebral level. The tip of the spinal cord is called the conus.

Below the conus, there is a spray of spinal roots that is frequently called the cauda equina or horse’s tail.

Injuries to T12 and L1 Vertebrae damage the lumbar cord. Injuries to L2 frequently damage the conus.

Injuries below L2 usually involve the cauda equina and represent injuries to spinal roots rather than the spinal cord proper.

Question 5

Vertebral Segments

Answer 5

The verterbal column is composed of a series of 31 separate bones. There are 7 cervical (neck), 12 thoracic (chest), 5 lumbar (back), and 5 sacral (tail) vertebrae.

The vertebrae are defined by the spinal cord segments and are not necessarily situated at the same vertebral levels. For example, while the C1 Cord is located at the C1 Vertebra, the C8 Cord is situated at the C7 Vertebra.

Question 6

Spinal Cord Injuries assigned to MDC 1 Include

Answer 6

Concussion
Edema
Incomplete and complete lesions
Central and anterior cord syndrome
Injury of the cauda equina

Question 7

Central cord syndrome is characterized as

Answer 7

An incomplete traumatic injury to the cervical spinal cord. The injury is considered “incomplete” because patients are usually not completely paralyzed.

Question 8

Anterior spinal cord syndrome is characterized as

Answer 8

Involves complete motor paralysis and loss of temperature and pain perception distal to the lesion.

Question 9

Cauda Equina Syndrome

Answer 9

Occurs when the bundle of nerves below the end of the spinal cord is damaged from trauma, disc herniation, or other conditions like stenosis

Question 10

Cauda Equina Syndrome
* Clinical Indicators
* Treatment
* Complications

Answer 10

Clinical Indicators: Include low back pain that radiates into the leg, anal numbness, bladder/bowel incontinence.

Treatment: Involves surgical intervention

Complications: Neurogenic bladder/bowel, sexual dysfunction.

The onset of the patient’s symptoms depends on the mechanism of injury – acutely from trauma or gradual from herniation or stenosis.

Question 11

Postop Hematoma with Cauda Equina Syndrome - Coding Clinic 3Q2020, p20

Question: A patient, who was diagnosed with cauda equina syndrome from L3-L4 and L4-L5 epidural hematoma, status post L3-L5 bilateral decompression laminectomy, underwent evacuation of the hematoma with additional decompression of L2-L3.

What is the correct diagnosis code assignment for the epidural hematoma? Is an additional code reported for cauda equina syndrome?

Coding Clinic Advice

Answer 11

Answer: Assign code G97.61, Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure. An epidural hematoma is a hematoma of the central nervous system, and decompressive lumbar laminectomy is a nervous system procedure. Also assign code G83.4, Cauda equina syndrome.

Explanation: This patient was diagnosed with cauda equina syndrome from a post-op hematoma at L3-L5 occurring after a decompression laminectomy. The HIM professional seeks advice concerning the coding and reporting of the epidural hematoma and cauda equina syndrome. The hematoma is assigned as a postoperative hematoma of the nervous system – not the musculoskeletal system – even though the complication was associated with an orthopedic procedure. The CES is captured with code G83.4.

Question 12

Spinal Cord Injury Complications generally occur how long after the initial injury

Answer 12

Acute complications of a spinal cord injury generally occur within the first 48 hours of the injury.

Question 13

Neurogenic Shock

Spinal Cord Injury Complications

Answer 13

A distributive type of shock that is attributed to the disruption of the autonomic pathways within the spinal cord.
* Clinical indicators: instantaneous hypotension due to sudden, massive vasodilation; warm, flushed skin due to vasodilation; priapism; bradycardia.
* Treatment includes dopamine, vasopressors, atropine.

Question 14

When a patient with a Spinal Cord Injury presents with a concomitant diagnosis of Acute Respiratory Failure, what is assigned as the PDX?

Spinal Cord Injury Complications

Answer 14

Assignment of principal diagnosis is dependent on the circumstances of the admission.

If the clinical evidence of respiratory failure exists but the diagnosis is not documented, ask a question!

Question 15

What is the MSDRG Assignment of the following?

PDX: Spinal Cord Injury
with
Mechanical Ventilation

Answer 15

MSDRG Assignment
53 (Neuro MDC)

Question 16

What is the MSDRG Assignment of the following?

PDX: Cervical Neck Fracture
with
Mechanical Ventilation

Answer 16

MSDRG Assignment
552 (Ortho MDC)

Question 17

What is the MSDRG Assignment of the following?

PDX: Acute Respiratory Failure
with
Mechanical Ventilation

Answer 17

MSDRG Assignment
189 (Resp MDC)

Question 18

Acute respiratory failure
* When a patient is admitted to the hospital with a diagnosis of Acute Respiratory Failure POA and it is confirmed to be responsible for occasioning the admission, is it assigned as the PDX or Secondary DX?
* What Chapter-Specific Coding Guidelines take precedence in sequencing direction?

Answer 18

A code from subcategory J96.0, Acute respiratory failure, or subcategory J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List.

However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

Question 19

Acute respiratory failure
* When is Acute Respiratory Failure listed as the Secondary Diagnosis?

Answer 19

Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.

Remember chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

Question 20

Sequencing of acute respiratory failure and another acute condition

Answer 20

When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations.

If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

Question 21

Mechanical Ventilation
* What is the Root Operation & Define it.
* Is Mechanical Ventilation a valid or non-valid OR procedure?

Answer 21

During mechanical ventilation, a machine is performing the respiratory cycle for the patient.
* The root operation for mechanical ventilation is PERFORMANCE.
* Performance: Completely taking over a physiological function by extracorporeal means

Mechanical ventilation is a non-valid procedure

Question 22

Hypostatic Pneumonia

Spinal Cord Injury Complication

Answer 22

• Caused by passive or dependent congestion of the lungs.
• Clinical indicators: pulmonary vascular congestion on CXR, hypoxia, tachycardia, tachypnea, low-grade temp, nonproductive cough, mildly elevated WBC.
• Treatment includes O2 support, serial CXRs, bronchodilators, antibiotics.

Question 23

Pressure Ulcers/Injuries

Spinal Cord Injury Complication

Answer 23

Patients with a spinal cord injury are at risk for developing pressure ulcers/injuries involving the bony prominences and the back of the head. A pressure injury may be considered a hospital acquired condition. If this condition occurs after the time of admission, it will be captured as a secondary diagnosis but disallowed from impacting the DRG assignment as a reimbursable secondary diagnosis.

Ensure the present on admission status of the pressure ulcer/injury is well documented.

Question 24

Spasticity

Spinal Cord Injury Complication

Answer 24

Spasticity is caused by an imbalance between signals that inhibit or stimulate the spinal cord. This results in hyperexcitable stretch reflexes, increased muscle tone, and involuntary movements. Baclofen is a muscle relaxant medicine commonly used to decrease spasticity related to spinal cord injuries.

Question 24

The insertion of a Baclofen pump
* Is it a valid or non-valid OR procedure?
* What Root Operation is used?
* In addition to the Baclofen pump, what else is indexed for the insertion? Is it indexed with the same Root Operation?

Answer 24

The insertion of a Baclofen pump is a valid OR procedure and will influence DRG assignment.

Index the insertion of the Baclofen pump and catheter with the root operation INSERTION.

0JH80VZ Insertion of Infusion Pump into subcutaneous tissue and fascia, abdomen, open approach
AND

00HU33Z Insertion of infusion device into spinal canal, percutaneous approach

Question 25

Official Guidelines: Neoplasms
Treatment directed at the malignancy
Treatment of secondary site

Answer 25

• If the treatment is directed at the malignancy, you’ll assign the malignancy as the principal diagnosis.
• But if the treatment is directed toward a secondary site, you’ll assign the secondary site as the principal diagnosis even if the primary site still exists.

The only exception to the Treatment directed at the malignancy guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy, assign the appropriate Z51.– code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.

Question 26

Brain Cancer
* Clinical Indicators
* Complications

Answer 26

• Clinical indicators of brain cancer are directly related to the location of the tumor. Some symptoms will overlap while others are location specific.
• Complications: obstructed flow of CSF, brain herniation, hemorrhagic stroke, hemiparesis, acute respiratory failure.

Primary brain cancer rarely spreads beyond the central nervous system and is much less common than secondary or metastatic brain tumors. In adults, the most common types of cancer that spread to the brain are melanoma, breast, renal cell carcinoma, colorectal cancer, and lung cancer.

Question 27

Frontal Lobe Tumor Symptoms

Brain Cancer

Answer 27

Behavioral and emotional changes
Impaired judgment
Impaired sense of smell
Memory loss
Paralysis on one side of the body
Reduced cognitive function
Vision loss and/or papilledema

Question 28

Parietal Lobe Tumor Symptoms

Brain Cancer

Answer 28

Impaired speech
Inability to write
Lack of recognition
Seizures
Spatial disorders

Question 29

Occipital Lobe Tumor Symptoms

Brain Cancer

Answer 29

Vision Loss

Question 30

Temporal Lobe Tumor Symptoms

Brain Cancer

Answer 30

Impaired speech
Seizures

Question 31

Brainstem Tumor Symptoms

Brain Cancer

Answer 31

Behavioral and emotional changes
Dysphagia
Drowsiness
Headache especially in the morning
Hearing loss
Muscle weakness on one side of the face
Uncoordinated gait
Vision loss
Ptosis
Strabismus
Vomiting

Question 32

Meninges Tumor Symptoms

Brain Cancer

Answer 32

Headache
Hearing Loss
Dysphagia
Incontinence
Mental and Emotional Changes
Somnolence
Seizures
Vision Loss

Question 33

Cerebral Edema
* Often developed as a component of what disease process
* Clinical Indicators
* Treatment

Answer 33

• Patient with brain cancer often develop this as a component of the disease process.
• Clinical indicators include HA, dizziness, nausea, lethargy, loss of coordination, inability to see/speak, seizures, incontinence, AMS.
• Treatment may involve the administration of mannitol, controlled hyperventilation, hypertonic NaCL infusion, induced hypothermia, barbiturates.

barbiturates aim to decrease the total fluid volume within the brain either by reducing the interstitial fluid and/or by reducing cerebral blood flow

Question 34

Brain Compression
* What is occurring to the brain during this process?
* What term is often used by the radiologist to describe this condition?
* Clinical Indicators
* Risk Factors
* Treatment

Answer 34

• The brain is being pressed out of its normal placement by blood, fluid, or a tumor. The radiologist often describes this condition as a “midline shift.”
• Clinical indicators: drowsiness, altered respirations, weak/thready pulse, increase intracranial pressure, paralysis, coma, death.
• Risk factors include brain bleeds, brain infection, brain tumors.
• Treatment involves identifying and treating the underlying cause (not a spinal tap!).

The primary treatment plan involves treating the underlying cause and decreasing intracranial pressure. Spinal tap is disregarded as a treatment option as the sudden decrease in pressure may cause herniation of the brain.

Question 35

Brain Compression Clinical Example

Scenario: This 34 yo female was admitted earlier today from home. She was found to have a 2x3cm mass within the right frontal lobe. Her symptoms include increasing drowsiness and a thready pulse. The stat CT of the head also showed a “midline shift.” She has been taken urgently to the OR for surgical intervention.

Sample Clarification

This scenario describes a 34-year-old female admitted with a frontal lobe mass.

Read the scenario, then click the Sample Clarification tab, and finally click the Explanation tab for additional information.

Answer 35

Sample Clarification:
* Right frontal lobe mass with brain compression requiring urgent surgical intervention
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: increasing drowsiness, thready pulse, midline shift per CT
Risk Factor: 2x3cm mass within the frontal lobe
Treatment:craniectomy

Explanation: This clinical scenario involves a 34-year-old female admitted with a frontal lobe mass. Her symptoms include increasing drowsiness and a thready pulse with a CT that’s positive for a significant midline shift. The clinical evidence suggests brain compression requiring urgent surgical intervention. It’s evident by the patient’s presentation this potential secondary diagnosis has significantly increased her risk of mortality. If the evidence is there – always ask the question.

Question 36

Shift, Mass Effect, and Brain Compression - Coding Clinic 3Q2011, p11

Question: The patient suffered an acute subdural hematoma with shift and mass effect. We have been instructed by a consultant that shift and mass effect are clinically synonymous with brain compression and should be coded as such.

Would it be appropriate to assign Compression of brain, based on the provider’s documentation of “mass effect or midline shift”?

Answer 36

Answer: The coder should not make the assumption that midline shift or mass effect is synonymous with brain compression. The coder should query the provider and if the provider clarifies and documents that the “mass effect” or “midline shift” is brain compression, the coder may then assign a code for the brain compression.

Explanation: Although the patient in the scenario doesn’t have a malignancy, the advice is still applicable. The HIM professional seeks advice for capturing a diagnosis of brain compression based on a description of mass effect or midline shift. According to Coding Clinic, we should not make assumptions regarding the diagnosis inferred by the physician’s clinical description but should seek further clarification of a definitive diagnosis.

Question 37

Chemo via Craniotomy
* What Root Operation is used for patients requiring Chemotherapy administration via Craniotomy
* What must the coder ensure to capture for appropriate DRG Assignment?

Answer 37

Some patients with brain cancer require the administration of chemotherapy directly into the brain. You will use the root operation INTRODUCTION to index the implantation of the chemotherapeutic agent via craniotomy.

Important Note: Remember to capture all the procedures necessary for appropriate DRG assignment: craniotomy + the introduction of the chemotherapy.

Introduction: putting in or on a therapeutic substance except blood or blood products

Question 38

Carotid Stenosis
* Definition
* Carotid stenosis is caused by?
* The most common location for sclerotic plaque to collect?
* Clinical Indicators
* Risk Factors
* Treatment

Occlusions

Answer 38

• A narrowing of the carotid arteries, the two major arteries that carry oxygen-rich blood from the heart to the brain.
• Caused by atherosclerosis inside the artery wall that reduces blood flow to the brain.
• The most common location for the sclerotic plaque to collect is at the fork between the internal and external carotid arteries.
• Clinical Indicators: TIA.
• Risk factors include atherosclerosis, obesity, CAD, family hx, age.
• Treatment would include meds for stenosis < 50%, surgical intervention for TIA/stroke.

Carotid Stenosis occurs due to sclerotic plaque accumulation in the vessel. As long as the plaque is stable, it may remain asymptomatic. But in some instances, a small piece can break off and travel to the brain, causing temporary ischemia (a TIA) or permanent damage (a stroke).

Surgical treatment is generally recommended for patients who have suffered one or more TIAs/strokes and who have a moderate to high grade of carotid stenosis. The aim of surgery is to prevent stroke by removing or reducing the plaque buildup and enlarging the artery lumen to allow more blood flow to the brain.

Question 39

External Carotid Artery

Answer 39

Supply blood to the face and scalp

Question 40

Internal Carotid Artery

Answer 40

Supply blood to the brain

Question 41

Carotid Bifurcation

Answer 41

Where the common carotid divides into the internal and external carotid arteries

*This is the most common location of Atherosclerotic plaque buildup

Question 42

Common Carotid

Answer 42

The carotid artery begins at the aorta as the common carotid and courses up through the neck to the head.

Near the larynx, the common carotid divides into the external and internal carotid arteries

Question 43

Aorta

Answer 43

The main and largest artery in the human body

Question 44

Carotid Endarterectomy
* What occurs during this procedure?
* What is the Root Operation used to index the procedure?

Answer 44

During this procedure, the surgeon incises the carotid artery, and the plaque buildup is physically peeled out and removed. Use the root operation EXTIRPATION to index the procedure.

Extirpation: taking/cutting out solid matter

Question 45

Carotid Stenting
* What occurs during a carotid percutaneous transluminal angioplasty (PTA)?
* What Root Operation is used to index this procedure?
* How is the stent managed in the documentation of this code assignment?

Answer 45

• During a carotid percutaneous transluminal angioplasty (PTA), the carotid artery is dilated, and a stent is inserted.
• You’ll use the root operation DILATION to index the procedure – the stent is incorporated into the code assignment.

Dilation: altering the diameter or route of a tubular body part to expand an orifice or lumen

Question 46

Carotid Stenosis Documentation Management
* Carotid Stenosis is usually caused by?
* Carotid Stenosis can also be a late complication of what disease process?
* What must the coder do, especially if there are other late complications?

Answer 46

Carotid stenosis is usually caused by atherosclerosis; HOWEVER, carotid stenosis can be a late complication of diabetes since atherosclerosis is accelerated in both type 1 and type 2 diabetes

If clinically appropriate, seek clarification of a cause-and-effect relationship between your patient’s stenosis and their diabetes, especially if they have other late complications, e.g., ESRD, retinopathy. For this diabetic complication there is no assumed link – the physician must document the condition.

Question 47

Important Notes about Carotid Stenosis
* Carotid Stenosis is considered what type of diagnosis?
* DM-related Carotid Stenosis is considered what type of diagnosis?

How do you index DM-related Carotid Stenosis?

Answer 47

Carotid stenosis is considered a neuro diagnosis (MDC 1).
DM-related carotid stenosis is considered a circulatory diagnosis (MDC 5).

To index DM-related carotid stenosis:
diabetes>with>circulatory complication NEC.

Question 48

Diabetes with Atherosclerosis - 1Q2002, p7

Question: The patient was admitted with carotid artery stenosis for which endarterectomy was done. The patient also has a history of type 2 diabetes mellitus. The work-up included vascular studies with findings of generalized atherosclerosis and peripheral vascular disease (i.e., femoral artery stenosis, iliac artery stenosis, and renal artery stenosis). When queried regarding the relationship between the vessel disease and the diabetes, the physician recorded the diagnostic statement of diabetes contributory to atherosclerosis.

Since the physician related the atherosclerosis to the diabetes, should this condition be assigned to code 250.70, Diabetes with peripheral circulatory disorders?

Answer 48

Answer:
* Assign code 433.10, Occlusion and stenosis of precerebral arteries, carotid artery, without mention of cerebral infarction, as the principal diagnosis.
* Assign code 250.00, Diabetes mellitus without mention of complication, type II [non-insulin dependent type [NIDDM type] [adult-onset type] or un-specified type, not stated as uncontrolled, for the diabetes as a secondary diagnosis.
* Code also any other reportable secondary diagnoses.

The physician did not indicate a direct causal relationship between the diabetes and the atherosclerosis. As previously stated in Coding Clinic, Second Quarter 1994, page 17, do not assume a causative relationship, if the physician does not establish one. Although the diabetes may have may have contributed to the patient’s condition, according to the health record documentation, the patient had other contributory factors (e.g., two pack per day tobacco abuse, hypertension, sedentary life-style, family history, etc.).

Explanation: In this clinical situation, a patient is admitted with carotid stenosis and undergoes a CEA. He does have a history of type 2 diabetes. The physician is queried regarding a cause-and-effect relationship but doesn’t quite document the condition adequately enough. Pay particular attention to the second paragraph in Coding Clinic’s response on the Answer tab.

Question 49

Sample Clarification Example

Clinical Scenario: A 67 yo male presents as an elective admission for right internal carotid artery stenting. The patient has a diagnosis of “high grade stenosis” but no associated infarction or neurological deficits. He has a 17-year history of type II diabetes, CKD stage 3, and neuropathy involving both feet. He manages his diabetes with diet and exercise but over the last 6 months his A1C has begun to increase requiring supplemental insulin injections.

Documentation Validation

Review this scenario and consider how you would format the clarification to prompt the physician to accurately document the condition.

Now use the Clinical Evidence Checklist to format your physician clarification.

What is the physician thinking and treating but not documenting? Once you are done, click Continue to see what a possible clarification might look like.

Answer 49

Clarification Example
* Carotid stenosis d/t type II diabetes requiring treatment with stenting
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: high grade stenosis of the right internal carotid artery
Risk Factors: 17-year history of type II diabetes with CKD and neuropathy
Treatment: carotid artery stenting

Question 50

Transient Ischemic Attack (TIA)
* What is a TIA defined as?
* When reviewing the EMR of a patient admitted with a TIA, what should the coder spend time closely reviewing? Why?

Answer 50

A sudden focal loss of neurological function caused by a transient period of inadequate perfusion to the brain

• When reviewing the medical record of this patient’s admission, spend time closely reviewing the associated neurological deficits (focal or global) to determine if an opportunity exists to refine the principal diagnosis.

Question 51

FOCAL Deficits
* Focal Deficits include?
* Alternative diagnostic options based on Focal Deficits?

Answer 51

Deficits Include:
paralysis
seizures
impaired sensation
visual disturbances
inability to coordinate fine motor movement
difficulty word finding
slurred speech

Alternative Diagnostic Options based on deficits:
stroke
embolic TIA due to cerebral embolism
carotid stenosis
carotid stenosis due to diabetes

Question 52

Embolic TIA
* An Embolic TIA occurs when?
* Is this considered a transient or prolonged event?
* Clinical Indicators
* Risk Factors
* Treatment

Answer 52

• This TIA occurs when a blood clot or mass of blood cells (embolism) forms somewhere in the body, breaks free, then becomes lodged in one of the blood vessels in the brain.
• This TIA is a transient event.
• Clinical indicators: numbness of face/extremities, confusion, dimming of the vision, speech difficulty, loss of coordination, sudden severe HA (clinical indicators usually clear within 24 hrs.)
• Risk factors include afib, mitral/aortic valve disease, SSS, sustained Aflutter, recent MI, CHF with EF <30%, cardiomyopathy, infectious endocarditis, CABG, left ventricular aneurysm.
• Treatment involves anticoagulation and supportive care.

The clinical indicators associated with an embolic TIA may mimic those associated with an embolic stroke

Question 53

How is an Embolic TIA Indexed

Answer 53

The diagnosis of embolic TIA cannot be indexed, so even if the MD documented “embolic TIA,” it could not be coded by the coding professional.

You will need to link the condition back to the probable underlying cause, i.e., cerebral embolism.

Question 54

Embolic TIA Clinical Example

Scenario: A 72 yo male has been admitted with “TIA” after stroke was ruled out in the ED. This patient has a significant cardiac history including Afib and CHF with a documented EF of 27%. His home medications include coumadin. His facial numbness and confusion have cleared within 4 hours of onset; a repeat CT of the brain will be performed in the AM with discharge anticipated shortly after. He will remain on neuro checks and his daily coumadin until DC.

Sample Clarification

Answer 54

Sample Clarification
* Embolic TIA d/t cerebral embolism in the setting of afib and CHF requiring additional diagnostic study
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: confusion and facial numbness which cleared within 4 hours
Risk Factors: afib and CHF with low EF
Treatment: inpatient admission with additional diagnostic study – repeat CT of head, neuro checks, coumadin

Explanation: This patient was admitted with TIA. He has a history of atrial fibrillation and CHF with an EF of 27%. His presenting symptoms - facial numbness and confusion - have cleared within 4 hours of onset. His treatment regimen includes anticoagulation and supportive care. Note the diagnostic option is formatted for “embolic TIA d/t cerebral embolism” – that’s because a diagnosis of embolic TIA cannot be indexed.

Question 55

Global Deficits
* Global Deficits include?
* Alternative diagnostic options based on Global Deficits?

Answer 55

Deficits Include:
decreasing cognitive function
personality changes
lethargy
altered mental status
nystagmus
headache
ataxia
decreasing level of consciousness
Alternative Diagnostic Options:

Alternative Diagnostic Options based on deficits:
encephalopathy
carotid sinus syncope

Question 56

Carotid Sinus Syncope
* This conditions results from overstimulation of?
* Clinical Indicators
* Risk Factors
* Diagnostics
* Treatment

Answer 56

• Results from overstimulation of the baroreceptors in the carotid sinus found in the neck.
• Clinical indicators – syncope, unexplained falls, retrograde amnesia, hypotension.
• Risk factors include man >50 yo, hx of HTN, CAD, Lewy body disease, neck tumors, neck scarring.
• Diagnostics – carotid massage, tilt-table test, EKG, doppler.
• Treatment involves patient education and/or pacer insertion.

The stimulation of these receptors causes the heart rate to drop along with the blood pressure with eventual loss of consciousness due to transient diminished cerebral perfusion.

Question 57

Clinical Scenario: This 59 yo female has been admitted “s/p TIA.” Her clinical presentation included mild hypotension and amnesia concerning the precipitating event, which has now cleared. Her MRI of the head was negative. Discharge is expected in the AM, but she will remain on q30 minutes neuro checks for the next 4 hours. Your review of the documentation reveals the patient was getting a massage of her neck and shoulders at the mall just prior to her TIA.

Question:
1) The clinical Evidence supports this potential alternative PDx:
A. Embolic TIA
B. Carotid Stenosis
C. Carotid Sinus Syncope

TIA Testing Knowledge

Answer 57

Answer: C. Carotid Sinus Syncope
Based on her clinical presentation, risk factor and treatment, the correct answer is CSS.

Question 58

Stroke
* A CVA is categorized as the rapid loss of brain function due to what?
* What risk factors put a patient at risk for stroke?
* Stroke can be classified into what two major categorires? How do the two categories occurs?
* Are Clinical Indicators the same for all types of strokes?

Answer 58

• The disease process categorized by the rapid loss of brain function due to a disturbance in the blood supply to the brain.
• Risk Factors: Age, HTN, hx of stroke or recurrent TIA, DM, high cholesterol smoking and afib
• This disease process can be classified into two major categories: ischemic and hemorrhagic.

The ischemic process occurs due to an occlusion affecting blood flow in the brain.
The hemorrhagic process occurs when a blood vessel ruptures.

• Clinical Indicators differ according to the category

Question 59

Ischemic Stroke
* Usually occurs due to?
* Clinical Indicators
* What is the primary treatment for Ischemic Stroke?

Answer 59

Usually occurs due to an occlusion affecting blood flow in the brain

• Clinical Indicators include sudden numbness of face/extremities, acute onset of confusion and/or difficulty speaking, loss of vision in one or both eyes, loss of coordination, acute onset of severe HA.
• Treatment: tPA

Occurs as a result of an obstruction (thrombosis, embolism) within the blood vessel. Ischemic strokes account for over 85% of all stroke admissions.

Question 60

Hemorrhagic stroke
* Occurs when?
* Clinical Indicators
* Treatment focuses on?

Answer 60

Occurs when a blood vessel ruptures
* Clinical Indicators include LOC, N/V, acute onset HA, weakness, seizure, loss of coordination, difficulty speaking/swallowing, confusion.
* Treatment: focuses on controlling the bleeding into the brain (surgical clipping, endovascular embolization, stereotactic radiosurgery) and reducing pressure in the brain.

Occurs when a weakened blood vessel ruptures (aneurysm or AVM). However, the most common cause is uncontrolled hypertension.

Question 61

Official Guidelines: NIHSS Stroke Scale
* According to the Official Guidelines, at a minimum, what score must be reported?
* Is the score reported as a PDx or Secondary Dx? Can it be captured from clinical team members other than the Physician?
* The Stroke Scale is a tool used to evaluate what status in acute stroke patients? What does the tool assess?

Answer 61

• According to the official guidelines, at a minimum, report the initial score documented in the medical record.
• The score can be captured and reported as a secondary diagnosis from clinical team members other than the physician.
• The stroke scale is a 15-item clinical assessment tool used to evaluate and document neurological status in acute stroke patients.
• The tool assesses for level of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.

It is likely your patient’s stroke will be clinically defined using a stroke score. The score lends additional description to the patient’s neurological status and the severity of the stroke.

Question 62

Stroke: Common Secondary Diagnoses

Answer 62

Encephalopathy*
Cerebral Edema
Brain Compression
Brain Herniation
Hemorrhagic Conversion*
Seizure
Adverse Effect of tPA*
Acute Respiratory Failure
Aspiration Pneumonia
Acute Tubular Necrosis
Hemiplegia*

Stroke concomitant conditions increase SOI and ROM.

The secondary or concomitant conditions a stroke patient experiences can significantly increase severity of illness and risk of mortality. According to the CDC, someone in the United States has a stroke every 40 seconds, however, every 4 minutes, someone succumbs to stroke, further underscoring the importance of capturing all conditions contributing to the patient’s risk of mortality. If the clinical evidence suggests one or more of these diagnoses, you’ll need to ask the question.

Question 63

Acute Lacunar Infarct with Encephalopathy - Coding Clinic 4Q2018, p13

Question: A patient is admitted to the hospital due to altered mental status, gait imbalance and vertigo. The patient is diagnosed with an acute lacunar infarct and encephalopathy secondary to the lacunar infarction.

How should this be coded?

Coding Clinic Advice

Answer 63

Answer: Assign code I63.81, Other cerebral infarction due to occlusion or stenosis of small artery, for the lacunar infarct. In addition, assign code G93.49, Other encephalopathy, as a secondary diagnosis, since the encephalopathy is not inherent to the lacunar infarct.

Explanation: One of the conditions listed in the previous section was encephalopathy – a diffuse dysfunction of the brain. Coding Clinic addresses the issue of capturing encephalopathy in a patient with a stroke in this 2018 advice. The patient is diagnosed with an acute lacunar infarct and encephalopathy due to the infarction. According to Coding Clinic, encephalopathy is not inherent to the infarction and should be coded and reported.

Remember, if your stroke patient has clinical evidence of encephalopathy but it has not been documented, ask the question.

Question 64

Frontal Cerebral Infarction - Coding Clinic 3Q2010, p5

Question: A patient sustained a left frontal cerebral infarction with hemorrhagic conversion. The provider documented that the patient had presented with expressive aphasia due to an acute cerebral infarct and later developed hemorrhagic conversion of the infarct. When queried, the provider stated that the hemorrhagic conversion had occurred spontaneously.

What are the correct code assignments for spontaneous hemorrhagic conversion of a cerebral infarction?

Coding Clinic Advice

Answer 64

Answer: Assign both code 434.91, Cerebral artery occlusion, unspecified, with cerebral infarction and code 431, Intracerebral hemorrhage. Hemorrhage can spontaneously occur after the original infarct.

Explanation: Here’s an interesting clinical situation: A patient was admitted with a left frontal cerebral infarction and then developed a spontaneous hemorrhagic conversion. The HIM professional seeks advice for the coding of the spontaneous hemorrhagic conversion. According to Coding Clinic, you’ll capture both conditions, the cerebral infarction and the nontraumatic intracerebral hemorrhage.

Question 65

Coding Clinic Advice

Question: A patient was given tPA after being admitted through the emergency department (ED) for sudden onset of weakness and difficulty speaking. The provider diagnosed ischemic infarction of the left posterior cerebral artery. A repeat computed tomography (CT) scan showed hemorrhagic conversion of the left posterior cerebral artery ischemic stroke. When the provider was queried regarding cause and effect between the tPA and the hemorrhagic conversion, he responded that there was no relationship; the hemorrhage occurred after the tPA had worn off.

What is the diagnosis code assignment for the hemorrhagic conversion?

Cerebral Artery Infarction with Hemorrhagic Conversion - Coding Clinic 2Q2017, p8

Answer 65

Answer: In this case, the provider has confirmed that the hemorrhagic conversion is not an adverse effect of tPA. Assign code I63.532, Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery, for the initial infarction as the principal diagnosis. Assign the appropriate code from category I61, Nontraumatic intracerebral hemorrhage, for the hemorrhagic conversion as an additional diagnosis.

Question 66

Hemorrhagic Transformation of Ischemic Stroke

Answer 66

A term used to describe an infarction that occurs following venous thrombosis or arterial thrombosis and embolism (an ischemic event).
* HT occurs within 2-14 days post ischemic event, usually within the first week and in about 10% of patients.
* Clinical indicators of conversion: HA, dizziness, neck rigidity, neurological deterioration.
* Risk factors include advanced age, HTN, smoking, DM, afib, hyperlipidemia, chronic renal insufficiency, tx with thrombolytics, large artery infarcts.
* Treatment depends on severity but may require ICP management, ventricular drain insertion, crani.

Many patients can be asymptomatic with petechial hemorrhages. Headache, dizziness, or neck rigidity, neurologic deterioration such as gradual loss of consciousness, stupor, or coma may occur

Question 67

Hemorrhagic Conversion of Ischemic Stroke
Important Documentation Strategies
* During the Acute CVA Event, are additional manifestations assigned?
* After the acute event has passed what diagnoses are assigned?

Answer 67

Important Note: during the acute CVA/stroke event, assign the patient’s additional manifestations, like dysphagia, or hemiparesis. Ex: acute cerebral infarction d/t thrombosis of the right middle cerebral artery with dysphagia

“Sequela” diagnoses are assigned after the acute event has passed. Ex: R26.89, Other abnormalities of gait and mobility, I69.398, Other sequelae of cerebral infarction

Question 68

Hemiplegia - Coding Clinic 1Q2014, p23

Question: Does the advice from Coding Clinic, First Quarter 2010, page 5, regarding the coding of neurologic deficits caused by CVA even when they have resolved at the time of discharge from hospital hold true for ICD-10-CM as well?

Coding Clinic Advice

Answer 68

Answer: Hemiplegia is not inherent to an acute cerebrovascular accident (CVA). Therefore, it should be coded even if the hemiplegia resolves, with or without treatment. The hemiplegia affects the care that the patient receives.
Report any neurological deficits caused by a CVA even when they have been resolved at the time of discharge from the hospital.

Explanation: Hemiplegia may not be considered as acute as some of the other secondary conditions, but it does influence the patient’s physical, mental, and emotional well-being. In this 2014 question to Coding Clinic, the HIM professional seeks advice regarding the appropriateness of coding resolved hemiplegia in a stroke patient. According to Coding Clinic, you’ll report any neurological deficit caused by the CVA even when resolved at the time of discharge.

Question 69

Chronic Cerebrovascular Accident - Coding Clinic 2Q2020, p29

Question: An 84-year-old male with chronic gait instability is admitted after a fall. The provider’s documentation states that the patient’s gait instability is related to chronic cerebrovascular accident (CVA). How is gait instability due to chronic CVA coded?

Coding Clinic Advice

Answer 69

Answer: Although the index leads to code I63.9, Cerebral infarction, unspecified, based on the documentation, the patient does not have a current cerebrovascular infarction. Assign code R26.89, Other abnormalities of gait and mobility and code I69.398, Other sequelae of cerebral infarction. The gait instability is coded as a late effect or sequela (neurological deficit), associated with the patient’s previous CVA.

Explanation: This patient does not have an acute or current CVA. He has sequela of an old event. You’ll assign a code for the sequela (R26.89, Other abnormalities of gait and mobility) along with the code to reflect the deficit as sequela (I69.398, Other sequelae of cerebral infarction) of the previous cerebral infarction.

Question 70

Sequela of CVA/Hemorrhage

Answer 70

Some CVA or brain bleed patients may not fully recover, instead developing sequela due to the insult to the brain.

Important Note: Sequela are the late effects after an acute phase of an illness has terminated. Common sequela of CVA include paraplegia, weakness, seizures, and dysphagia.

Question 71

Respiratory Failure
* Acute Respiratory Failure is often a concomitant diagnosis in which patients?
* How is the sequencingof respiratory failure as the principal diagnosis affected?

CVA/Stroke/Hemorrhage Documentation Management

Answer 71

• It is not uncommon for patients with brain hemorrhages or infarctions to present with a concomitant diagnosis of this diagnosis.
• Consider sequencing the patient’s respiratory failure as the principal diagnosis if clinically appropriate, especially if the patient requires mechanical ventilation.

If the respiratory failure is present on admission and the patient requires mechanical ventilation, assign the respiratory failure as the principal diagnosis – if the patient did not require mechanical ventilation, assign the CVA as the principal diagnosis.

As a reminder, mechanical ventilation will only impact your patient’s MSDRG assignment with a respiratory, sepsis, or burn principal diagnosis, or in certain tracheostomy situations.

Question 72

Aspiration Pneumonia
* What should the coder look for in the patient’s EMR?
* How is the sequencing of the PDx affected in a CVA patient with the concomitant diagnosis of Aspiration PNA?

CVA/Stroke/Hemorrhage Documentation Management

Answer 72

Review the patient’s chest x-ray for the clinical indications of an infiltrate that was present on admission, especially if the patient presented with respiratory compromise. Also review the EMS run sheet or ED notes for documentation of evidence the patient vomited prior to arrival.

Consider sequencing the patient’s aspiration pneumonia as the PDx if clinically appropriate, especially if the patient requires mechanical ventilation. This sequencing option more accurately reflects your patient’s SOI and ROM

Another concomitant diagnosis of CVA is aspiration pneumonia. It is not uncommon for a patient who experiences a CVA to vomit and aspirate during the event. By the time the patient reaches the acute care facility, the aspiration pneumonia may already be evident on chest x-ray. If aspiration pneumonia is not documented but the clinical evidence suggests the diagnosis, seek clarification from the physician.

Question 73

Stroke d/t Methamphetamine Poisoning
* In a patient admitted with a hemorrhagic stroke, what should the coder look for a PMHx of?
* If the Physician links the bleed to the illicit drug use, what is assigned as the PDx? Is a secondary diagnosis required?

Answer 73

In the patient admitted with a hemorrhagic stroke such as a subarachnoid hemorrhage, look for a medical history of methamphetamine abuse, especially in younger individuals.

If the physician links the bleed to the illicit drug use, methamphetamine poisoning will be assigned as the patient’s PDx with the CVA assigned as a secondary diagnosis.

This would not be considered an adverse effect.

Question 74

SAH d/t Meth Use Clinical Example

Scenario: A 32 yo male arrived via EMS with sudden onset of severe headache with slurred speech and ataxia after injecting “crank.” The patient has a known history of Methamphetamine abuse but no other known medical history. BP on arrival was 182/120, pulse 122. The stat CT of the brain showed a small subarachnoid hemorrhage. The patient was admitted to ICU and treated with Nicardipine IV, Labetalol IV prn with MAP >130mg/Hg, allowing permissive HTN, neurological checks every 1 hour, head of bed up to 30 degrees, Dilantin IV, repeat CT of the brain, and possible surgical intervention.

Sample Clarification

In this clinical example, a 32-year-old male is admitted with a small subarachnoid bleed after smoking methamphetamine.

Read the scenario, then click the Sample Clarification tab, and finally click the Explanation tab for additional information.

Answer 74

Sample Clarification:
* Subarachnoid hemorrhage due to methamphetamine abuse requiring ICU admission with close monitoring
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: small subarachnoid hemorrhage, severe headache with slurred speech and ataxia after smoking methamphetamine, elevated BP and pulse
Risk Factor: methamphetamine abuse
Treatment: ICU admission, Nicardipine IV, Labetalol IV prn, with MAP >130mg/Hg allowing permissive HTN, neuro checks every 1 hour, HOB 30 degrees, Dilantin IV, repeat CT, possible surgical intervention

Explanation: In this clinical example, a 32-year-old male is admitted with a small subarachnoid bleed after smoking methamphetamine. Review the CDS’s clarification to the physician and the clinical evidence she used to support her question.

Question 75

CVA due to Cardioversion
* If a patient is admitted for CVA and has had cardioversion recently, the coder should review the medical record closely for?
* What becomes the PDx and what becomes the secondary diagnosis?
* How is this indexed?

Answer 75

• If a patient is admitted for CVA and has had cardioversion recently, review the medical record closely. If the evidence supports a cause-and-effect relationship, ask the question.

The complication (postprocedural complication of the circulatory system) would be assigned as PDx and the manifestation (CVA) as a secondary diagnosis.

To index: complication>circulatory system>postprocedural

Question 76

CVA due to Cardioversion Clinical Example

Scenario: An 82 yo male admitted to the floor last night underwent a successful TEE and cardioversion for atrial fibrillation 2 days ago; post procedure he was placed on Xarelto. The patient stated he was eating dinner and had sudden onset of right facial droop with numbness, slurred speech and weakness with his right hand. The head CT head was negative; however, the brain MRI demonstrated a tiny 3 mm focus of restricted diffusion in the left lobe representing a possible small acute ischemic infarct. Cardiology and neurology were consulted. This morning, his symptoms were completely resolved. The neurologist documented, “Acute stroke, embolic event following a TEE cardioversion.” The cardiologist documented, “Acute CVA, likely embolic. The patient is on Xarelto, switch to Eliquis and ASA.”

Sample Clarification

This scenario reviews the application of the CVA due to cardioversion documentation strategy.
Read the scenario and then click the Sample Clarification tab for additional information.

Answer 76

Sample Clarification:
* CVA, likely embolic resulting from TEE cardioversion requiring Eliquis and ASA
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: right facial droop with numbness, slurred speech and weakness with his right hand, brain MRI demonstrated a 3 mm focus of restricted diffusion in the left lobe representing a possible small acute ischemic infarct
Risk Factor: TEE cardioversion for atrial fibrillation 2 days prior to CVA
Treatment: MRI brain, cardiology consult, neurology consult, Eliquis, ASA

Question 77

tPA Administration
* What is the role of tPA administration? What types of strokes is tPA associated with?
* Is tPA a valid or non-valid OR procedure? Will this procedure affect the DRG Assignment?
* What are the requirements necessary to be captured for appropriate DRG Assignment of tPA administration?
* The CDS should review what notes for tPA administration? Why?
* What is the Root Operation used to index this procedure?

Answer 77

• Pharmacologic thrombolysis (“clot busting”) with the drug tissue plasminogen activator (tPA), is used to dissolve the clots associated with ischemic strokes.
• The administration of tPA is a NON-valid OR procedure which will impact your patient’s DRG assignment (DRGs 61-63).
• Remember to capture all the requirements necessary for appropriate DRG assignment: ischemic stroke + tPA administration
• The CDS should review the ED notes for tPA administration.
• Use the root operation INTRODUCTION to index the administration of the tPA (or thrombolytic agent).

The CDS should review the ED notes for tPA administration because tPA is usually given within 3-4.5 hours of the onset of ischemic stroke symptoms; is not indicated for hemorrhagic strokes.

The Root Operation Introduction is used for tPA Administration. Although the drug is administered in the clinical sense, the root operation you’ll use to index the procedure is “introduction” since the clinical team is putting a therapeutic substance into the patient’s body.

Question 78

Adverse Effect of tPA and Hemorrhagic Conversion of Ischemic Stroke

Question: A patient was started on tissue plasminogen activator (tPA) after presenting to the emergency department (ED) with expressive aphasia and was diagnosed with an ischemic stroke. A repeat computed tomography (CT) scan showed left stroke with hemorrhagic transformation. The provider was queried regarding the hemorrhagic transformation and stated that the tPA therapy had caused hemorrhagic conversion of the ischemic stroke.

What is the diagnosis code assignment for the hemorrhagic conversion of the ischemic stroke?

Coding Clinic 2Q2017, p8

Answer 78

Answer: In this case, the patient had an ischemic stroke, and after tPA was administered as prescribed, he developed hemorrhaging into the area of the infarct. Therefore, the cerebral hemorrhage is coded as an adverse effect of the medication (tPA), rather than as a complication.

Assign code I63.8, Other cerebral infarction, for the initial ischemic stroke. In addition, assign the appropriate code from category I61, Nontraumatic intracerebral hemorrhage, along with code T45.615A, Adverse effect of thrombolytic drugs, initial encounter, for the hemorrhagic transformation following administration of tPA.

Explanation: In this clinical scenario, the patient presented with an ischemic stroke and was treated with tPA. After treatment with tPA, the patient developed hemorrhaging into the area of the ischemic infarction. The physician clarified the hemorrhagic conversion was due to the tPA. In this case, assign the ischemic stroke as your principal diagnosis with additional diagnoses for the intracerebral hemorrhage and adverse effect to the thrombolytic drug.

Question 79

Testing Knowledge - CVA

Clinical Scenario: This 72 yo female has been admitted with a large “CVA.” In the ED she was described as obtunded with acute hypoxia; O2 sat of 64% on RA with a RR of 9. She was immediately intubated with subsequent initiation of mechanical ventilation. Her current diagnoses include CVA with acute respiratory insufficiency – she remains on MV.

Questions
1) What is the patient’s principal diagnosis?
A. CVA
B. Obtunded state
C. Acute Hypoxia
D. Acute respiratory Insufficiency

2) What is a potential alternative principal diagnosis?
A. CVA
B. Obtunded state
C. Acute Hypoxia
D. Acute Respiratory Failure

3) What is the appropriate root operation for mechanical ventilation?
A. Extripation
B. Introduction
C. Insertion
D. Performance

4) Is mechanical ventilation a valid OR procedure?
A. Yes
B. No

Answer 79

Answers:
1) A. CVA
2) D. Acute Respiratory Failure
3) D. Performance
4) B. No

Explanation: Initially we consider the CVA as the patient’s principal diagnosis. But close review of her clinical presentation reveals she was likely in acute respiratory failure on arrival to the ED. If you ask this question and the physician agrees, you’ll assign the respiratory failure as the principal diagnosis and capture the acuity of the ventilator. Index the ventilator with the root operation performance even though it is not a valid OR procedure

Question 80

Testing Knowledge - CVA

Clinical Scenario: A 54 yo male was admitted earlier today with a large spontaneous “intracranial bleed.” The stat CT of the head showed a “significant midline shift.” He has been taken urgently to the OR for surgical intervention.

Questions:
1) What is the patient’s principal diagnosis?

2) What is a potential secondary diagnosis?
A. CVA
B. Seizure
C. Brain Compression
D. Adverse effect of tPA

3) True or False: The CDS may assign a diagnosis rendered by a physician not directly involved in the care and treatment of the patient, ex: the radiologist.

4)True or False: Post-operatively the patient remained on MV for 97 hours; this MV duration influences your MSDRG assignment.

Answer 80

Answers:
1) Acceptable responses: intracranial bleed, large spontaneous intracranial bleed, spontaneous intracranial bleed, intracranial hemorrhage
2) C. Brain Compression
3) False
4) False

Explanation: Without question this patient’s principal diagnosis is the intracranial bleed. But the midline shift identified by the radiologist is suggestive of brain compression, a secondary diagnosis that reflects a significantly high mortality rate. And even if the radiologist had described the condition as brain compression, the CDS would not be allowed to capture the condition documented by a physician not directly involved in the care and treatment of the patient. The number of hours the patient remained of the vent has no influence in this clinical situation.

Question 81

Encephalopathy
* Encephalopathy is the term used to describe?
* What are the clinical indicators? What is the hallmark symptom?
* Treatment involves?
* Can Encephalopathy, AMS, and Confusion be used interchangeably?

Answer 81

• The term used to describe diffuse dysfunction of the brain.
• The clinical indicators depend on the type and severity – the hallmark symptom is altered mental status. Other common symptoms include loss of memory, decreased cognition, poor concentration, personality changes, lethargy with progressive LOC.
• Treatment involves identifying and treating the underlying cause.

Encephalopathy, Altered Mental Status, and Confusion are NOT interchangeable terms.

Question 82

Hypertensive Encephalopathy
* Clinical Indicators
* Risk Factors
* Treatment

Specific types of encephalopathy in MDC 1

Answer 82

• Encephalopathy often associated with HTN emergency.
• Clinical indicators include vomiting, visual disturbances, HA, focal neurological deficits, seizures.
• Risk Factors – HTN, glomerulonephritis, eclampsia, stroke.
• Treatment requires IV Na nitroprusside (Nitropress) and careful monitoring.

Diagnostics:
* MRI of the brain often reveals a pattern of (reversible) cerebral edema occurring in the occiput and frontal areas of the brain in late or untreated cases.
* Lumbar puncture may show normal or elevated CSF pressure and protein.
* The diagnosis of hypertensive encephalopathy is established when lowering the blood pressure results in rapid resolution of symptoms.

Treatment: Sodium nitroprusside given by continuous intravenous infusion lowers the blood pressure. The patient must be carefully monitored, and the infusion rate adjusted to maintain a therapeutic effect without producing hypotension.

Question 83

Documentation Validation

Clinical Scenario: A 65 yo male with a history of hypertension has been admitted with a “hypertensive crisis” associated with N/V, AMS, and a nosebleed.

He required treatment with emergent IV Nitropress in the ED for a BP noted at 210/130; he has been admitted to ICU with a treatment regimen which includes CT of the head, neuro checks q30 minutes, 02 support and continuation of the IV nitroprusside.

Specific types of encephalopathy in MDC 1

This scenario will require you to identify the clinical indicators for a secondary diagnosis of hypertensive encephalopathy.
Now use the clinical evidence checklist to format your physician clarification and supporting evidence in your MDC notes.

What is the physician thinking and treating but not documenting? Once you are done, click Continue to see what a possible clarification might look like.

Answer 83

Clarification Example
* Hypertensive encephalopathy due to hypertensive crisis requiring treatment with IV Labetalol.
* Other; with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record reflects the following clinical evidence:
Clinical Indicators: N/V, altered mental status, nosebleed, BP 210/130
Risk Factors: history of hypertension
Treatment: IV Nitropress, neuro checks, CT of the head, O2 support, admission to ICU

Question 84

Metabolic Encephalopathy
* Metabolic Encephalopathy is a diffuse dysfunction of the brain caused by?
* Clinical Indicators include
* Risk Factors

Specific types of encephalopathy in MDC 1

Answer 84

• A diffuse dysfunction of the brain caused by an underlying systemic illness or condition.
• Clinical indicators – AMS, tremor, myoclonus, stupor, coma, seizures; the EEG may show slowing of background rhythms.
• Risk factors include electrolyte imbalance, acute/chronic renal failure, sepsis, hypoxia, malnutrition, non-infectious SIRS, brain tumors stroke, cerebral ischemia.
• Treatment requires identifying and treating the underlying cause.

Clinical Indicators: The main features of reversible metabolic encephalopathy are confusion, typified by disorientation and inattentiveness and accompanied in certain special instances by asterixis, tremor, and myoclonus, usually without signs of focal cerebral disease. This state may progress in stages to one of stupor and coma. Slowing of the background rhythms in EEG reflects the severity of the metabolic disturbance. Seizures may or may not occur, most being associated with particular underlying causes of encephalopathy such as hyponatremia and hyperosmolarity.

The primary plan of care is treatment of the underlying cause.

Question 85

Metabolic Encephalopathy Clinical Example

Scenario A 72 yo male presents to the ED from the physician’s office as a direct admission. In the office he was found to have a NA level of 112 along with complaints of nausea, altered mental status, and muscle twitching with general weakness

VS - 97.8, P92, R18, BP 122/64, 02 sat 98% on RA
PMH - HTN
Meds - Norvasc
Diagnostics - Na 112, CT of head negative for acute process

Impressions –

ED: low sodium with AMS…saline bolus infusing
H&P: hyponatremia and AMS…endocrine consult pending
PN: hyponatremia, delirium…CT of head negative…continue neuro checks q1 hours, repeat NA level

Sample Clarification

This scenario demonstrates the importance of closely reviewing the clinical presentation and the documentation used by the physician to describe that presentation.

Answer 85

Sample Clarification
* Metabolic encephalopathy due to severe hyponatremia, being treated with saline boluses
* Other, with explanation of the clinical findings
* Unable to determine (no explanation for the clinical findings)

The medical record includes the following clinical evidence:
Clinical Indicators: AMS, muscle twitching with weakness, nausea, negative head CT
Risk Factor: severe hyponatremia
Treatment: IV saline boluses, monitoring of VS/neuro checks/labs, endocrine consult

Explanation: In this situation, the physician documents the patient has been admitted with a low sodium level and altered mental status. This is the opportunity to work with the physician to refine a diagnosis that accurately reflects the patient’s severity of illness.

Question 86

Encephalopathy d/t Sepsis - 2Q2017, p7

Question: A patient is admitted with mental status changes and is diagnosed with severe sepsis secondary to urinary tract infection, acute renal failure and acute encephalopathy. The provider documented “sepsis associated encephalopathy.”

How should the encephalopathy be coded (G94 vs. G93.41)?

Answer 86

Answer:
Assign code G93.41, Metabolic encephalopathy, for sepsis-associated encephalopathy. This code assignment can be found in the Index under:
Encephalopathy (acute)
septic G93.41

Code G94, Other disorders of brain in diseases classified elsewhere, should only be assigned for those conditions with Index entries that directly point to code G94 for certain etiologies; otherwise assign code G93.40, Encephalopathy, unspecified, if the type of encephalopathy is not documented. Assign a more specific code, when the type of encephalopathy is documented.

Explanation: The patient in question was diagnosed with sepsis, UTI and septic encephalopathy. According to Coding Clinic, you’ll index the condition as septic encephalopathy which just happens to assign to the same code as metabolic encephalopathy.

Question 87

Toxic Encephalopathy

Specific types of encephalopathy in MDC 1

Answer 87

• A global cerebral dysfunction associated with exposure to neurotoxins (organic solvents, some gases, heavy metals, drugs).
• Clinical indicators – depends on the toxin and intensity of exposure (mild euphoria, stupor, seizure, coma, death).
• Treatment is primarily supportive after removal of the exposure source.

Question 88

Acute Lacunar Infarct with Encephalopathy - Coding Clinic 4Q2018, p13

Question: A patient is admitted to the hospital due to altered mental status, gait imbalance and vertigo. The patient is diagnosed with an acute lacunar infarct and encephalopathy secondary to the lacunar infarction.

How should this be coded?

Coding Clinic Advice

Answer 88

Answer:
Assign code I63.81, Other cerebral infarction due to occlusion or stenosis of small artery, for the lacunar infarct. In addition, assign code G93.49, Other encephalopathy, as a secondary diagnosis, since the encephalopathy is not inherent to the lacunar infarct.

Explanation: We reviewed this Coding Clinic in the first MDC 1 module. As a reminder, encephalopathy is not considered inherent to stroke.

If your infarction patient has evidence of encephalopathy, but it has yet to be documented, ask the question.

Question 89

Encephalopathy d/t UTI - Coding Clinic 2Q2018, p17

Question: A patient is diagnosed with encephalopathy due to urinary tract infection (UTI).

Is code G94, Other disorders of brain in diseases classified elsewhere, assigned? How should encephalopathy due to UTI be coded?

Coding Clinic Advice

Answer 89

Answer:
Assign codes G93.49, Other encephalopathy, and N39.0, Urinary tract infection, site not specified. The sequencing of the principal diagnosis would be based on the condition found after study to be responsible for the hospital admission.

As stated in Coding Clinic Second Quarter 2017, pages 8-9, code G94, Other disorders of brain in diseases classified elsewhere, should only be assigned for those conditions with Index entries that directly point to code G94, for certain etiologies.

Explanation: Here’s an interesting question: if a patient is diagnosed with encephalopathy due to a UTI, how should it be captured and coded? According to Coding Clinic, the appropriate diagnosis and code is G93.49, other encephalopathy. Assignment of principal diagnosis is dependent on the circumstances of the admission. Of note, encephalopathy is considered a potential organ dysfunction associated with sepsis. If your patient is admitted with UTI and encephalopathy – review the clinical evidence closely. You may find an opportunity to seek clarification for sepsis.

Question 90

Seizure with Encephalopathy d/t Postictal State

Question:

The patient is a 70-year-old female who presented to the emergency department (ED) because of mental status change. While in the ED, she had a tonic-clonic seizure that was witnessed by staff. The patient had no previous history of seizure and was admitted as an inpatient for further evaluation and management. In the discharge summary, the provider noted, “On admission the patient had mental status changes, which subsequently resolved. Consequently, we have determined that the patient had encephalopathy secondary to postictal state.”

Should encephalopathy be reported as an additional diagnosis with seizure when it’s due to a postictal state? Would the encephalopathy be considered inherent to the seizure or can it be separately reported?

Coding Clinic Advice - Coding Clinic 4Q2013, p89

Answer 90

Answer: Assign code 780.39, Other convulsions, as the principal diagnosis. The encephalopathy due to postictal state is not coded separately since it is integral to the condition. Seizure activity may be followed by a period of decreased function in regions controlled by the seizure focus and the surrounding brain. The postictal state is a transient deficit, occurring between the end of an epileptic seizure and the patient’s return to baseline. This period of decreased functioning in the postictal period usually lasts less than 48 hours.

Question 91

Autonomic Neuropathy
* Clinical Indicators
* Risk Factors
* Treatment

Answer 91

• Disorders affecting the peripheral nerves, particularly the nerves that automatically and without conscious effort regulate body processes, such as blood pressure
• Autonomic neuropathy a type of peripheral neuropathy, a disorder in which the peripheral nerves are damaged throughout the body.
• Clinical indicators – orthostasis, erectile dysfunction, urinary incontinence, urinary retention, gastroparesis, constipation.
• Risk factors include DM, amyloidosis, autoimmune diseases, MS, Parkinsons disease, cancer, drugs, ETOH, toxin exposure.
• Treatment requires identifying and treating the underlying cause, immunosuppressants, immunoglobulin, plasma exchange.