Neurosurgery Coding Alert

Plus, know how to determine the principal diagnosis.

As a neurosurgery coder, you will encounter instances in which a prior injury, illness, or disease will exhibit new signs or symptoms after the initial injury or illness has subsided. These manifestations from the previous trauma or illness, also known as sequela effects, can be extremely difficult to grasp from a ICD-10-CM coding perspective.

While there are numerous diagnostic considerations to take into account, you've also got to consider the rules ICD-10-CM has implemented in coding for such sequelaeffects.

Check out this helpful guide of examples and expert advice to help steer you to success when confronted with any sequela coding scenario.

Sequela Defined

The ICD-10-CM guidelines define a sequela effect as the following:

• "A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury."

With respect to the neurosurgery specialty, sequela effects can take on numerous shapes and forms. For instance, a patient may experience sequela effects following trauma to the central nervous system (CNS). For example, if a patient suffers from intracranial bleeding following trauma, this would simply be considered a component of the acute injury, not a sequela. Additionally, if the patient experiences headaches in the days and weeks while recovering from the trauma, you would also not consider these symptoms to be sequela effects.

However, if the patient experiences symptoms (headache, cognitive, behavioral, neurological) in the months and years since the patient has fully recovered from the initial traumatic incident, you may consider these symptoms to be sequela effects. The same idea applies to other areas of the CNS, as well.

Follow the Guidelines on Sequela Coding

As you will see in the ICD-10-CM guidelines, the information on sequela coding isn't necessarily localized to one particular section. With this in mind, it's important that coders know how to maneuver through the guidelines to identify all the vital elements within their search criteria.

The first point of reference comes with identifying the number and order of codes assigned. ICD-10-CM guidelines state:

• "Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second."

Example: If a patient experiences dizziness one year following a diffuse traumatic brain injury with loss of consciousness, you would code the following diagnoses in the following order:

• R42 - Dizziness and giddiness
• S06.2X9S - Diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela

ICD-10-CM uses the example of scar formation following a burn to illustrate the point of using two separate ICD-10-CM codes:

• "7th character 'S', sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character 'S', it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The 'S' is added only to the injury code, not the sequela code. The 7th character 'S' identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code."

However, before you go searching for two separate codes, consider these supplementary guidelines:

• "An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect."

There's a few points to unpack here. First, you won't necessarily come across many, if any, examples of a sequela followed by a manifestation code note in the ICD-10-CM tabular. On the other hand, you may come across examples in which a sequela code has been expanded to include manifestations.

Example: A patient experiences dysphagia four months following a cerebral infarction.

Here, it would be inappropriate to apply two separate codes (dysphagia, cerebral infarction) because one sequela manifestation code already exists. In this example, you would solely apply the following code:

• I69.391 - Dysphagia following cerebral infarction.

Caution: Using the above as an example, there may be instances in which it is difficult to differentiate whether » or not the dysphagia is an acute (or chronic) effect versus a sequela effect.

"The codes presented in the I69 series are used to report late effects (sequela) of cerebral infarction or hemorrhage and should be used any time after the initial encounter for the stroke," states Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City, Utah. "This essentially means that you use non-I69 codes to describe dysphagia or paralysis that is identified during the hospitalization for stroke. Once the patient is released from the hospital and is being seen for follow-ups, therapies, or other exams, coders should switch to the sequela codes in category I69 to describe the deficit," Bernard explains.