Neurosurgery Coding Alert

Duration of unconsciousness is your main guide.

ICD-9 offers a single code for cerebral edema (i.e. 348.5, Cerebral edema). However, the ICD-10 options are multiple and varied. Acquaint yourself with all possible options for cerebral edema to avoid going astray when ICD-10 is implemented. 

ICD-10 codes: You are wrong if you believe ICD-10 has a single code to offer for cerebral edema (i.e., G93.6, Cerebral edema). The ICD-9 code 348.5 also maps to 10 more codes for traumatic cerebral edema.

Ascertain Trauma as Cause for Cerebral Edema

When your physician documents cerebral edema due to trauma, you have specific codes in ICD-10. The first step for you is to confirm the cerebral edema was due to trauma. Next you should confirm if there was any loss of consciousness documented by your physician in the clinical note. When your physician documents no loss of consciousness with traumatic cerebral edema, you report ICD-10 code S06.1X0A (Traumatic cerebral edema without loss of consciousness, initial encounter). 

Find Duration of Loss of Consciousness

When your physician documents loss of consciousness, you should make sure your physician also documents the duration for which consciousness was lost. This will guide your choice of ICD-10 code when there is loss of consciousness with traumatic cerebral edema.  “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,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Depending upon the duration of loss of consciousness, you 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

Duration not specific: When your 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).

Check Return to Conscious Levels 

When your physician 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.  “Unfortunately, some patients never regain consciousness, with some dying from secondary brain injury as a consequence of the cerebral edema.”  You accordingly select form the following two 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

Be Specific For Death

Your physician may document death in a patient who was being treated for traumatic cerebral edema. In this case, you need to ascertain if the cause of death was brain injury or any other condition. “Cerebral edema can result in secondary additional brain injury,” Przybylski says. In more severe circumstances, sufficient uncontrollable cerebral edema can result in cerebral ischemia that may lead to “brain death” as a result of blood flow depravation to the viable brain tissue. If your physician documents death due to brain injury in a patient who was unconscious due to traumatic brain edema, you report code S06.1X7A (Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter). If, however, the death was due to a cause other than the brain injury, you report code S06.1X8A (Traumatic cerebral edema with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter).