ED Coding and Reimbursement Alert

Question: What diagnosis codes would you assign for the following patient encounter?

Hx: Patient is a 69-year-old mother, who is right handed and provides a history of a four day long severe headache with visual blurring and diplopia all right sided. She denied any Hx of seizures, motor sensory deficit, nausea and vomiting. No trauma or speech difficulties. She states she has had sinusitis for years. No current meds, NKDA.

Physical Examination: HEENT: Right pupil 2mm, reactive. Disconjugated gaze is present. There is right sided ptosis. Oropharynx clear without lesions. Her neck is supple without lymphadenopathy or thyromeagaly. Heart is regular rate with no irregular rhythms, murmurs, or gallops. Lungs are clear when auscultated and percussion normal. Neurologically she is alert and oriented times 3, follows three simple commands. Cranial Nerves show partial right sided third nerve palsy with ptosis, 3-mm nonreactive right pupil, right medial gaze with disconjugate extraoccular eye movements. Motor is 5/5throughout with drift. Finger test are within normal limits. Her sensory is intact to fine touch and proprioceptive: Cerebral Examination within normal limits.

MDM: Suspicious of S/S of intracranial aneurysm. Ultrasound demonstrated a posterior communication artery aneurysm. Patient was admitted for further evaluation and treatment with a diagnosis of a posterior communication artery aneurysm unruptured.

North Carolina Subscriber

Answer: The best diagnosis code assignment must clarify that the aneurysm had not ruptured.

On the Claim report:

ICD 9- CM principal Diagnosis Code 437.3 (Cerebral aneurysm, non-ruptured),

374.30 (Ptosis of eyelid, unspecified)

Under ICD 10, the codes would be I67.1 Cerebral aneurysm, non-ruptured, H02.401 (Unspecified ptois of right eyelid).

Keep in mind the additional granularity required for both documentation and coding demonstrated by this case. ICD 9 has one dominant code for unruptured cerebral aneurysms 437.3 and the ICD 10 conversion is nearly one to one with I67.1

However, the unspecified ptosis code can be expanded further to  further refine the anatomic detail to include right verse left eyelid and even upper verse lower lid involvement.