Monthly CDI Discussion – Brain Compression

Topic: Brain Compression

Scenario:

• 80 y/o m presents with c/o left sided weakness, limping, recent slurring of speech, and lethargy. Recent rollover MVC while out of the country – No CT/MRI head completed at that time.
• CT head reads – Large R SDH with approx. 1.3 cm midline shift and subfalcine herniation and impending transtentorial herniation
• Neurology (attending) documents etiology – traumatic
• H&P notes “brain compression”
• Attending states traumatic SDH in all progress notes
• Treatment: Mannitol 77gm IV given in ED
• To OR for Burr holes and evacuation of SDH with drain placed
• Op note states “Preoperative Diagnosis – Right parietal chronic subdural hematoma”
• Principal and secondary diagnoses: Traumatic subdural hemorrhage without loss of consciousness (S06.5X0A) and brain compression (G93.5)

Question: Would you capture brain compression (G93.5)?

Discussion:

• Brain compression documented and treated with IV medication and OR procedure
• G93.5 was assigned – However, as shown below, there is an Excludes 1 note for G93.5 which states to “exclude if traumatic”

• If traumatic, brain compression is assigned to codes S06.2- or S06.3- (diffuse or focal traumatic brain injury)

UASI Recommendation: Do not code G93.5. Recommend query to determine if brain compression is diffuse or local

CDI Educational Tips: When dealing with traumatic brain injury, be on the lookout for cerebral edema on imaging studies. If cerebral edema is present and qualifies as a secondary diagnosis (monitoring, neuro checks, treatment, etc.), you can capture code S06.1X0A – traumatic cerebral edema (MCC) as long as diffuse or focal traumatic brain injury is not also coded.

This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.