As the largest outsource coding provider in the country we have identified trends and gained unique insights from our coders throughout the transition to ICD-10. We are sharing these insights with the broader HIM Community through our bi-weekly blog series "ICD-10 Quick Tips."
The subject matter for this series is currated based on the trending topics in our online question and answer system which services over 1,200 of our HIM professionals. Our Subject Matter Experts have an average of 20 years of experience and are considered leaders in their field.
This week's post comes from National Compliance and Quality Audit Manager, Melissa McLeod, CDIP, CCDS, CCS, CPC, CPC-1, and AHIMA Approved ICD-10 Trainer.
After our last few blogs where we addressed a number of challenging coding topics, those being spinal fusions and aneurysm repairs (I know I heard you all groan again), we thought it was time for a ‘lighter’ topic. So let’s talk neurology! Neurology isn't so bad in the coding world, but there are a couple of little snippets we would like to share with you all as we continue to navigate through ICD-10. So here we go!
- When unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis/hemiplegia.
Pause . . . say what? When did that happen? When is anything synonymous in coding??
Coding Clinic 1st Quarter 2015 clarifies for us:
An 88-year-old male patient is admitted secondary to a cerebral infarction. In the final diagnostic statement, the provider documented “acute cerebral infarction involving the right hemisphere with left sided (nondominant) weakness.” How should left-sided weakness due to an acute cerebral infarction be coded when there is no specific mention of hemiplegia/hemiparesis?
Assign code I63.9, Cerebral infarction, unspecified, as the principal diagnosis. Assign code G81.94, Hemiplegia, unspecified affecting left nondominant side, as an additional diagnosis. When unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis/hemiplegia. Unilateral weakness outside of this clear association cannot be assumed as hemiparesis/hemiplegia, unless it is associated with some other brain disorder or injury.
Okay, so what about residual weakness after a CVA?
Coding Clinic 1st Quarter 2015 clarifies for us:
The patient is a 72-year-old male admitted to the hospital, because of gastrointestinal bleeding. The provider documented that the patient had a history of acute cerebral infarction with residual right sided weakness (dominant side), and ordered an evaluation by physical and occupational therapy. What is the appropriate code assignment for residual right-sided weakness, resulting from an old CVA without mention of hemiplegia/hemiparesis?
Assign code I69.351, Hemiplegia and hemiparesis following cerebral infarction, affecting right dominant side, for the residual right-sided weakness due to cerebral infarction. When unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis/hemiplegia. Unilateral weakness outside of this clear association cannot be assumed as hemiparesis/hemiplegia, unless it is associated with some other brain disorder or injury.
- The term Parkinsonism indicates that a person has symptoms similar to Parkinson’s disease. It does not necessarily mean that the person has Parkinson’s disease.
In Parkinson’s disease, brain cells that produce dopamine die. Symptoms such as tremors, stiffness, and slowness of movement are caused by a lack of dopamine. According to the National Parkinson Foundation, it is possible to have Parkinsonism without having Parkinson’s disease, with only 85 percent of all Parkinsonian syndromes due to Parkinson’s disease
In both the ICD-9-CM and ICD-10-CM indices the "see" instruction following the main term Parkinson’s disease indicates that the main term "Parkinsonism" should be referenced. This might cause the coder to conclude that Parkinson’s disease and Parkinsonism are synonymous terms, but they are not. Care should be taken to follow the index and tabular particularly when coding complications of Parkinson’s disease and Parkinsonism.
- Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than the term “chronic pain,” and therefore codes should only be used when the provider has specifically documented this condition.
Central pain syndrome is defined by the National Institute of Neurological Disorders and Stroke (NINDS) as “a neurological condition caused by damage to or dysfunction of the central nervous system.” Central pain syndrome can occur as a result of stroke, multiple sclerosis, neoplasm, epilepsy, CNS trauma, or Parkinson’s disease. ICD-10-CM classifies central pain syndrome to code 89.0 (Central pain syndrome).
Chronic pain syndrome is chronic pain associated with significant psychosocial dysfunction. The psychosocial problems may include depression, drug dependence, complaints that are out of proportion to the physical findings, anxiety, and other manifestations. You should code this condition only when the physician specifically documents it. Chronic pain syndrome is reported with code G89.4 (Chronic pain syndrome).
Well there you have it! A few little snippets to assist you in coding in the field of Neurology. Now we may not let you all get off so lightly next time…perhaps it’s time to address some OB/GYN coding? For my groaners out there…we can hear you!