Anesthesia Coding Alert

Heads up: You’ll have multiple options beginning Oct. 1.

When your provider administers anesthesia during a procedure to treat traumatic cerebral edema, you’ll need to work closely with the surgeon to determine the best ICD-10 diagnosis code. 

Here’s why: ICD-0 offers a single code for cerebral edema (348.5). ICD-10, however, includes multiple options for your consideration beginning Oct. 1. 

First steps: Confirm with the surgeon that the cerebral edema was due to trauma. Then, confirm whether the patient had any loss of consciousness that was documented in the record. If the patient did not experience loss of consciousness, you’ll report ICD-10 code S06.1X0A (Traumatic cerebral edema without loss of consciousness, initial encounter).

If the patient did lose consciousness, verify how long it lasted. This will guide your diagnosis coding because the new ICD-10 codes are based on the duration of lost consciousness.

“The duration of loss of consciousness may be associated with the degree of brain injury and therefore the severity and duration of post-injury cerebral edema that may occur,” explains Gregory Przybylski, MD, director of neurosurgery for the New Jersey Neuroscience Institute, JFK Medical Center, Edison. 

Depending upon the duration of loss of consciousness, you’ll select from the following codes:

• S06.1X1A – Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter

• S06.1X2A – Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, initial encounter

• S06.1X3A – Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

• S06.1X4A – Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, initial encounter. 

If the physician does not specify the duration of unconsciousness in a patient with traumatic cerebral edema, you report code S06.1X9A (Traumatic cerebral edema with loss of consciousness of unspecified duration, initial encounter). 

When the surgeon documents loss of consciousness lasting more than 24 hours, you need to check if the patient returned to pre-existing conscious levels. 

“Patients with severe head trauma may not regain consciousness for days or weeks, depending on the severity of the injury,” Przybylski says. 

If your anesthesia provider is involved in a procedure to treat the patient at this stage, you’ll choose between two diagnosis codes: 

• S06.1X5A – Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

• S06.1X6A – Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter.