ED Coding and Reimbursement Alert

Question: There are several symptoms listed but what’s the best diagnosis in this scenario?

Hx: present illness; Patient  is a 69-year-old mother, who is right handed and states for 4 days now has had a 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, NKA.

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 disconjugateextraoccular eye movement. 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.

Patient was admitted with suspicious S/S of intracranial aneurysm.

What should we report for these services?

Alabama Subscriber

Answer: Studies have shown that the physical findings of a 3^rd cranial nerve malfunction raises concern about a dangerous intra cerebral aneurysm. Importantly, the aneurysms with the highest rates of rupture (posterior communicating and basilar tip aneurysms) are also the aneurysms most likely to cause an isolatedcranial nerve III palsy. A key physical finding occurs when the patient not only has ptosis (drooping of the lid) but the pupil reaction is also abnormal. In these cases the risk of finding an aneurysm is particularly high because the nerve fibers supplying the pupil are especially susceptible to compression by an aneurysm.

Final Diagnosis: Right Posterior Communicating Artery Aneurysm; Anterior Communicating Artery Aneurysm; Right Otitis Externa.

ICD 9- CM principal Diagnosis Code 437.3 (Cerebral aneurysm, nonruptured), 380.22 (Other acute otitis externa)
Other ICD9-CM Diagnosis code 374.30 (Ptosis of eyelid, unspecified)

For future coding consider these ICD-10 Codes:
ICD 10-CM Diagnosis codeI67.1 Cerebral aneurysm, nonruptured, H02.401 (Unspecified ptosis of right eyelid).