Physician Advisor’s Corner: Wrapping Our Brains Around Cerebral Edema

By Andrew Maigur, MD, director of Physician Advisor Program

This article is meant to address the clinical documentation of non-traumatic cerebral edema in the medical record. The ICD-10 (International Classification of Disease) diagnosis code for non-traumatic cerebral edema, G93.6, serves as a major comorbid condition or complication. As a health system, we have noticed an increasing volume of clinical validation denials for cerebral edema. The reality of clinical validation denials is if the payer denies a condition that establishes a Diagnosis Related Group (DRG) or DRG tier, they may recoup reimbursement, which underscores the importance of accurate documentation in the medical record.

Two important questions should be considered:

• Is cerebral edema clinically significant?
• Is cerebral edema a valid secondary diagnosis? In other words, is cerebral edema supported by valid clinical indicators (signs and symptoms), imaging findings and intervention?

Common conditions that cause non-traumatic cerebral edema include ischemic and hemorrhagic strokes, brain tumors, infections, altitude sickness, electrolyte derangements, and toxins. However, the development of cerebral edema is not always inherent to the underlying etiology; for instance, not all ischemic strokes have surrounding vasogenic edema. It is an additional component which often complicates the clinical manifestations, treatment, and prognosis of the primary underlying condition.

It is important for clinicians to know the coder is not permitted to code exclusively from a radiology report. The clinician must declare the finding is clinically significant in the medical record. For cerebral edema to be a valid secondary diagnosis it is critical to link the diagnosis with associated clinical signs and symptoms (headache, nausea, vomiting, seizures, encephalopathy, Cushing's triad, papilledema), imaging findings (midline shift, mass-effect, sulci-basilar cistern effacement, brain herniation), and interventions. Treatment measures including IV Decadron, hypertonic saline infusion, and hyperventilation must be linked to the diagnosis of cerebral edema. Importing the radiology impression into your medical progress note does not clinically validate the diagnosis of cerebral edema. It is also essential to note that the diagnosis must be carried forward through the medical record and summarized in the discharge summary to be accurately captured by coders.

What about the patient with a guarded prognosis who elects comfort care measures? Does the lack of aggressive treatment render cerebral edema invalid as a secondary diagnosis? The answer is a resounding no. The key takeaway would be clear documentation of cerebral edema contributing to the grave prognosis, leading to the selection of comfort care measures.

To assist our clinical providers in accurate and consistent documentation of cerebral edema, Nivedita Mankotia, MD, and I have created a macro (tip sheet available on Provider Learning Home in EPIC). If you find yourself struggling to match the drop-down menu options with your patient, then it may be possible that cerebral edema is not clinically significant and/or a valid secondary diagnosis.

Back to the August 2020 issue of Premier Pulse