# Dx Coding for Hydrocephalus Patients



## maryv22 (Aug 2, 2017)

After reviewing below scenario, how would you code and sequence the diagnoses? - Would you code the symptoms first and then the hydrocephalus (headache-R51, nausea-R11.0, hydrocephalus-Q03.9)? Or instead of coding the hydrocephalus, code the presence of the CSF shunt (R51, R11.0, Z98.2)?

Assessment:  Pt has a history of congenital shunted hydrocephalus (has Strata valve set at 1.0 in place, connected to bilateral frontal caths, last revised 2 years ago), presenting with headache and nausea. Subtle increase in the size of the left lateral ventricle. Shunt system appears to be intact on shunt series.
-Imaging reviewed
-Pt appears to be feeling better on repeat exam
-Will admit for observation overnight
-Please obtain CBC, BMP, coags
-NPO after midnight
-Pain control w/ Tylenol

Any feedback is greatly appreciated.
Thanks!


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## jvilla (Aug 2, 2017)

*Would probably just code for hydrocephalus + shunt*



maryv22 said:


> After reviewing below scenario, how would you code and sequence the diagnoses? - Would you code the symptoms first and then the hydrocephalus (headache-R51, nausea-R11.0, hydrocephalus-Q03.9)? Or instead of coding the hydrocephalus, code the presence of the CSF shunt (R51, R11.0, Z98.2)?
> 
> Assessment:  Pt has a history of congenital shunted hydrocephalus (has Strata valve set at 1.0 in place, connected to bilateral frontal caths, last revised 2 years ago), presenting with headache and nausea. Subtle increase in the size of the left lateral ventricle. Shunt system appears to be intact on shunt series.
> -Imaging reviewed
> ...


According to https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2017-ICD-10-CM-Guidelines.pdf
*Signs and symptoms
*Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes _when a related definitive diagnosis has not
been established (confirmed) by the provider_. Chapter 18 of ICD-10-CM,
Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not
Elsewhere Classified (codes R00.0 - R99) contains many, but not all, codes for
symptoms.
See Section I.B.18 Use of Signs/Symptom/Unspecified Codes

*Conditions that are an integral part of a disease process*
Signs and symptoms that are associated routinely with a disease process should
not be assigned as additional codes, unless otherwise instructed by the
classification.

Per, https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Hydrocephalus-Fact-Sheet

Symptoms may include headache followed by vomiting, nausea, blurred or double vision, sun setting of the eyes, problems with balance, poor coordination, gait disturbance, urinary incontinence, slowing or loss of developmental progress, lethargy, drowsiness, irritability, or other changes in personality or cognition including memory loss.

Because congenital hydrocephalus is a chronic condition (usually caused by an obstructed cerebral aqueduct) that requires a shunt for _continuous_ treatment, I would personally not code any of the listed signs and symptoms.

Also, the documented ventriculomegaly is also integral to hydrocephalus. 

Just my two cents. Hope this helps.


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## Cynthia Hughes (Aug 2, 2017)

*Complication of ventricular shunt*



maryv22 said:


> After reviewing below scenario, how would you code and sequence the diagnoses? - Would you code the symptoms first and then the hydrocephalus (headache-R51, nausea-R11.0, hydrocephalus-Q03.9)? Or instead of coding the hydrocephalus, code the presence of the CSF shunt (R51, R11.0, Z98.2)?
> 
> Assessment:  Pt has a history of congenital shunted hydrocephalus (has Strata valve set at 1.0 in place, connected to bilateral frontal caths, last revised 2 years ago), presenting with headache and nausea. Subtle increase in the size of the left lateral ventricle. Shunt system appears to be intact on shunt series.
> -Imaging reviewed
> ...



Though the physician notes the increase in size of the left lateral ventricle as subtle (possible indication of failure to adequately drain fluid) and the shunt system appears to be intact, the patient is admitted for observation and additional work-up to determine the cause of the headache and nausea. The nausea and headache are common symptoms of a shunt malfunction as they are for hydrocephalus. I would query the physician regarding whether a diagnosis of complication of the ventricular shunt (e.g., T85.840-) is appropriate or if the cause of the headache and nausea were undetermined at the end of this encounter. While the presence of the shunt with these symptoms indicates a likely complication, the symptoms may also represent an unrelated illness. I would want to clarify and document the physician's intended diagnosis (and perhaps encourage clear documentation of the diagnoses as known at the time of encounter).  I hope that helps. Cindy


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## jvilla (Aug 2, 2017)

Cynthia Hughes said:


> Though the physician notes the increase in size of the left lateral ventricle as subtle (possible indication of failure to adequately drain fluid) and the shunt system appears to be intact, the patient is admitted for observation and additional work-up to determine the cause of the headache and nausea. The nausea and headache are common symptoms of a shunt malfunction as they are for hydrocephalus. I would query the physician regarding whether a diagnosis of complication of the ventricular shunt (e.g., T85.840-) is appropriate or if the cause of the headache and nausea were undetermined at the end of this encounter. While the presence of the shunt with these symptoms indicates a likely complication, the symptoms may also represent an unrelated illness. I would want to clarify and document the physician's intended diagnosis (and perhaps encourage clear documentation of the diagnoses as known at the time of encounter).  I hope that helps. Cindy



Excellent point!


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