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Monthly CDI Discussion – Brain Compression

April 4, 2019

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”
G93.5 Compression of brain
Arnold-Chiari type 1 compression of brain
Compression of brain (stem)
Herniation of brain(stem)
Excludes1:

    • diffuse traumatic compression of brain (S06.2-)
    • focal traumatic compression of brain (S06.3-)
  • 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.