Q&A: Coding ongoing encephalopathy after a subdural hematoma

Q: What would be the ideal way to code a case where a patient has ongoing encephalopathy after a subdural hematoma multiple years ago? I keep seeing documentation as a brain injury with ongoing encephalopathy, but is there a way to improve on this?

A: For starters, we’d need to know if the subdural hematoma was spontaneous or traumatic as this will require multiple diagnoses. You will need one code for sequelae, but you’ll need to know if it is a late effect of a trauma or cerebrovascular disease and then a separate code to identify the encephalopathy. Then you need to know the specific deficits as late effects of cerebrovascular disease codes get down into speech versus cognitive versus psychomotor deficits, etc. (Welcome to the coding world!)

Using the general codes (I think) I69.21, depending on if that would be considered intracranial, there is no code for subdural for spontaneous that I can find.

Next, I believe this qualifies as Encephalopathy NEC being that the type of encephalopathy is specified but since there is no ICD-10 Alphabetic Index entry for this scenario I would use G93.49.

If this was traumatic, code S06.5x9S with the S being the long-term sequelae.

Keep in mind that that, in order to determine the correct working DRG and possible query opportunities, it’s not necessary to agonize over the coding to this level. Those tasks and concerns are best left to the coders. It’s their area of expertise and CDI specialists should avoid duplicating their efforts.

If you use an I69 category you will be in DRG 056-057 and if you use the S06 category you will be in DRG 091 to 093. You just need to know the circumstances of the disease which is probably in the record already.

The CDI specialist has no control over the origin of the deficit (be it spontaneous versus traumatic), so there is really no return on our time in looking into this matter. However, if it is not clear in the record as to what led to the original subdural hematoma then, yes, a query would be needed to make sure the appropriate DRG was assigned.

A good use of the CDI specialist’s time would also be spent in determining if the encephalopathy is truly supported and reportable as a diagnosis for this record, i.e. clinical validation. We know encephalopathy is a diagnosis at high risk for denial.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.