Updated on: July 22, 2019

Clinical Validation Denials for Cerebral Edema are Increasing

Original story posted on: July 17, 2019

Wrapping your brain around Cerebral Edema

You may be noticing an uptick in clinical validation denials for cerebral edema. Here’s my take on this.

There are two distinct cerebral edema codes. They both serve as major comorbidity conditions or complications (MCCs).

  • Non-traumatic conditions, which are accompanied by cerebral edema, get the code G93.6, from the Diseases of the nervous system section. G93.6 has two principal diagnosis MCC exclusions – itself and G93.82, Brain death.
  • Traumatic cerebral edema is coded with S06.1-, stratified by duration of loss of consciousness. If there is no loss of consciousness, the PDx exclusions are the same as for G93.6. If there is any loss of consciousness, in addition to those two diagnoses, there are 337 traumatic conditions, which exclude traumatic cerebral edema as a MCC. These conditions include facial and skull fractures and other types of injuries, traumatic brain injuries and hemorrhages, suicide attempts, and traumatic compartment syndromes.

You can’t blame a payor for trying. The reality of clinical validation denials is that if they deny a condition that establishes a DRG or DRG tier, they may recoup money.

There are two basic questions to be considered:

  • Is cerebral edema inherent, or integral to the conditions that result in it?
  • Is cerebral edema a valid secondary diagnosis?

Cerebral edema doesn’t develop randomly, or out of the blue. Conditions that cause cerebral edema include traumatic brain injuries, ischemic and hemorrhagic strokes, brain tumors, infection, altitude sickness, electrolyte derangements, and toxins. However, the development of cerebral edema isn’t invariable; for instance, not all brain tumors have surrounding vasogenic edema. It is an additional facet or component, and therefore, it is eligible for additional coding. It often magnifies or complicates the clinical features of the primary underlying condition. The only Excludes 1 instructions are that a patient can’t have non-traumatic and traumatic cerebral edema concomitantly.

But should it always be picked up? This depends on whether the provider considers it clinically significant, and whether it meets the criteria for a valid secondary diagnosis. The provider will often not distinguish between the contribution of the underlying condition and the resultant cerebral edema or brain compression. The patient is undergoing an urgent decompressive surgery – and maybe it wouldn’t have been as urgent if the cerebral edema hadn’t been present. It is easier to identify when the treatment is Decadron or mannitol, because those are specifically targeted for edema.

What if the patient is given comfort care? Does this negate the validity of a secondary diagnosis because there is no treatment? The answer is a resounding “no.” The fact that the patient has the cerebral edema or brain compression may have rendered the prognosis sufficiently grave to cause the selection of comfort care.

The coder is not permitted to code exclusively from a radiology report. The clinician must establish that the finding is clinically significant. Indicators suggesting it could be significant are “mass effect” and “midline shift.” If the patient had a pre-operative assessment performed and was admitted for surgery, you are permitted to review the pre-op imaging, but you may need to query for clinical significance.

How can your providers ward off clinical validation denials? A best practice is that they make mention of cerebral edema without requiring a query prompt. Teach them that importing the radiology impression is not sufficient; they need to declare the clinical significance in their assessment and plan sections. Get them to incorporate the verbiage “clinically significant” in their documentation. Have cerebral edema be woven into the notes repeatedly, not just once in a single note. They should link the treatment and monitoring with the condition (e.g., “will start on Decadron for the cerebral edema and get repeat MRI in two weeks.”). It should also be present in the discharge summary.

Finally, clinical documentation improvement (CDI) teams should perform clinical validation queries when necessary. It is easier to fix it on the front end than to rework it on the basis of a clinical validation denial.

Cerebral edema is a legitimate, valid, important diagnosis. Get it documented in a codable format and code it.

Programming Note:

Listen to Dr. Erica Remer every Tuesday on Talk Ten Tuesday, 10-10:30 a.m. EST.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Erica E. Remer, MD, CCDS

Erica Remer, MD, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. She was a physician advisor of a large multi-hospital system for four years before transitioning to independent consulting in July 2016. Her passion is educating CDI specialists, coders, and healthcare providers with engaging, case-based presentations on documentation, CDI, and denials management topics. She has written numerous articles and serves as the co-host of Talk Ten Tuesdays, a weekly national podcast. Dr. Remer is a member of the ICD10monitor editorial board, a former member of the ACDIS Advisory Board, and the board of directors of the American College of Physician Advisors.

Related Stories

  • The OIG is Coming for your Malnutrition MCCs
    When I was a physician advisor, our system had a malnutrition crisis. It wasn’t that we had an explosion of unexpected cases; we were not getting the diagnosis captured when it was clinically present, relevant, and significant. When we created…
  • Sweeping Changes to Current CCs/MCCs Offer Cautionary Tale to CDISs
    CDISs urged to be prepared for changes. There is much to do on listserves and various conversations with colleagues to be had regarding the Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) proposed rule for the…
  • Searching for Efficiency in the CDI Process
    When efficiency is not truly efficient, after all. “Efficiency” may be defined in many ways, including the following, as described by dictionary.com: Able to accomplish something with the least waste of time and effort; competency in performance. An accomplishment or ability…