By Cesar M Limjoco, MD
Chief Medical Officer
I recently received the following question in a private LinkedIn message. I wrote two articles sometime ago that address the concern and thought I would reshare in order to help folks with the same issue.
Cerebral Edema/vasogenic edema: Do you think it is enough just mentioning of this diagnosis in the chart in order to code it as MCC or does the physician actually needs to document if this diagnosis is clinically significant or not. By clinically significant I mean: 1) treated 2) monitored 3) increased length of stay 4) increased nursing care. Thank you very much for your help in advance.
Here’s the article I wrote about this subject some time ago and published in the Journal of Nuclear Medicine and Biomedical Imaging (2) 1: 25-25.
CT/MRI Brain Scan Findings: Significant or Not?
Early radiographic signs of increased intracranial pressure such as mild vasogenic edema, slight midline shift or early uncal herniation may seem ominous to the lay person. But are they truly significant and impact on the patient’s health? Singularly, any of the above findings may not be clinically significant. But together, they may be ominous and signal impending death. One has to always correlate any abnormal findings to the patient’s signs and symptoms as well as the treatment modalities that are provided the patient. The above CT/MRI findings, when significant, may reflect an increased intracranial pressure from brain tumors, hematomas/hemorrhages, head injury, hydrocephalus, encephalitis/meningitis, strokes and seizures. The increased intracranial pressure can damage the brain or spinal cord by pressing on important structures and obstruction of blood flow into the brain. Increased intracranial pressure can be caused by increase in volume in the skull as may occur in cerebral contusion or laceration or intracranial bleed, rapidly enlarging mass or rapid accumulation of cerebrospinal fluid in the ventricles or it can be caused by brain swelling overall as in infections (encephalitis, encephalomyelitis, brain abscess) or can be vasogenic (the blood brain barrier is disrupted) as may occur around cerebral tumors or around any of the above conditions. Symptoms of increased intracranial pressure include: changes in mental status, behavioral changes, headaches, neurological symptoms (weakness, numbness, eye movement problems, double vision, seizures) and vomiting. Fundoscopic finding of papilledema occurs with several days of increased intracranial pressure. Increased pressure can result in reversible or permanent neurological problems, seizures, strokes/hemorrhage and death. Sudden increased intracranial pressure is life threatening and needs prompt treatment. Management involves mechanical and pharmacologic therapies. Head elevation is key to increase venous drainage from the brain. Hyperventilation induces hypocarbia and causes cerebral arterial vasoconstriction and reduces the intracranial pressure. Diuretics like Lasix and Mannitol draw the fluid out of the brain. Glucocorticoids like Decadron and Solumedrol reduce vasogenic edema and can cause marked improvement of symptoms. Draining the CSF fluid via a ventriculostomy or performing a decompressive craniotomy effectively reduces the pressure in the brain, regardless of cause. Neurosurgical removal of cause of the increased intracranial pressure will be the best means of controlling the intracranial pressure in the long run.
Here’s another article on abnormal findings that was published way back…
When to Clarify Abnormal Lab/Radiological/And Other Findings
“Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether a corresponding diagnosis should be added.” (ICD-10-CM Official Guidelines for Coding and Reporting)
“Coders are not allowed to assign codes directly from impressions included on diagnostic reports, such as x-rays, MRI, CT scans, electrocardiograms, echocardiograms, and pathology, even if a physician has signed the diagnostic report. The diagnosis must be confirmed by the physician in the body of the medical record (e.g., progress notes or discharge summary) before it can be coded. However, if the diagnostic report is adding specificity to an already-confirmed (physician-documented) diagnosis, then the coder may use the more specific code based on the diagnostic report without obtaining physician confirmation.” (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 5)
The basis for these guidelines — not all abnormal findings are significant. Trace tricuspid regurgitation, minimal cerebral edema, slight midline shift do not necessarily mean that these are significant pathological conditions that affect the patient. The corresponding radiologist, imaging specialist, or another reader reports them because they want to show that these abnormal findings may become significant in the future (but not yet at this time). But how is anyone to know when the abnormal finding has significance or not? Does every abnormal finding that is not confirmed by the attending need to be clarified? Will that generate a lot of queries that further embroil the providers and increase their frustration; or, should you ask for clarifications judiciously, when there is evidence that it may be significant? There are true positive findings that confirm the diagnosis; true negative findings that rule out the condition. But, there are also false positive findings and false negative findings. There are findings that are part and parcel of the disease; then, there are findings that connote a more severe condition. There are two principles that come to play here. Is the provider concerned with the finding and is 1.) ordering further workup to evaluate and monitor the condition; or, 2.) prescribing treatment for the condition? Either situation shows that the abnormal finding is now a significant condition.