ICD-10 Documentation Tips for Neurology and Neurosurgery

ICD-10 Documentation Tips for Neurology and Neurosurgery

Diagnosis

Alzheimer's Disease

Cerebral Infarction

Complications of Surgery Diabetic Neuropathy

Dominant or Nondominant Side Epilepsy

Malnutrition

Pathological Vertebral Fractures Pressure Ulcers Pulmonary Embolism

Respiratory Failure

Documentation Requirements

1) Document onset as: -Early or -Late

2) If with dementia, document as: -With behavioral disturbance, for example combative and/or aggressive behavior -Without behavioral disturbance

1) Document etiology as: -Thrombosis or -Embolism

1) Document timeframe of when complication occurred: -Intraoperatively -Postoperatively

1) Rather than "diabetic neuropathy," if known or suspected document instead: -Diabetic mononeuropathy -Diabetic polyneuropathy -Diabetic autonomic neuropathy -Diabetic amyotrophy -Other neurological complication

1) For monoplegia, hemiplegia, and other paralytic syndromes, document side affected as: -Dominant or -Nondominant

1) Elements of documentation should include: -Intractable versus not intractable and -With or without status epilepticus

1) Document type such as: -Protein calorie -Protein energy

1) Specify whether etiology is: -Age related or disuse osteopenia -Neoplastic -Some other disease

3) Document artery site and laterality when appropriate, such as: -Precerebral

-Vertebral, basilar, carotid, or other -Cerebral

-Middle, anterior, or posterior -Cerebellar arteries

2) Specify type of diabetes as Type 1 or Type 2

2) When you don't specify side affected as dominant or nondominant: -Right side defaults to dominant -Left side defaults to nondominant

2) Specify type, for example: -Localization-related idiopathic or symptomatic -Simple partial or complex partial seizures -Generalized idiopathic 2) Document severity: -Mild or 1st degree -Moderate or 2nd degree or -Severe or 3rd degree

3) If control of blood glucose level is not maintained, document insulin control status as: -Inadequately controlled -Out of controlled or -Poorly controlled

1) Site and stage needed for coding 2) Physician must document diagnosis of pressure ulcer

3) Stage of pressure ulcer can be taken from nursing notes

1) Document type, such as: -Saddle -Septic

1) Document: -Acute -Chronic or -Acute on chronic

2) Document cor pulmonale if present and whether it is: -Acute or -Chronic

2) If acute respiratory failure, document if: -Hypoxemic -Hypercapnic or -Both

3) Specify if: -Chronic (still present) versus -Healed/old -Note that "history of PE" is ambiguous

ICD-10 Documentation Tips for Neurology and Neurosurgery

Spinal Column Site

Nontraumatic Intracerebral and Subarachnoid Hemorrhage Nontraumatic Subdural Hemorrhage Sequelae of Cerebrovascular Disease

Transient Ischemic Attack (TIA)

Traumatic Brain Hemorrhage

Traumatic Vertebral Fractures

Procedure

Excision of Intervertebral Disc Spinal Fusion

1) For conditions of the spinal column, document site affected as: -Occipito-atlanto-axial -Cervical or cervical-thoracic -Thoracic or thoracolumbar -Lumbar or lumbosacral -Sacral or sacrococcygeal

1) For nontraumatic intracerebral

hemorrhage, document site as:

-Hemisphere

-Cerebellum

-Subcortical

-Intraventricular

-Cortical

-Multiple sites

-Brain stem

-Other

2) For spinal cord injury, document site as: -Cervical = identify each vertebral segment -Thoracic = identify as T1, T2-T6, T7T10, or T11-12 -Lumbar = identify each vertebral segment -Sacral = no additional specificity needed

2) For nontraumatic subarachnoid hemorrhage, document site and laterality when appropriate, such as: -Carotid siphon and bifurcation -Middle cerebral, anterior or posterior communicating, basilar, vertebral, or other artery

1) Document type:

-Acute

-Subacute

or

-Chronic

1) Use "due to" or "secondary to"

to link cause and effect. When

present, document sequelae, for

example:

-Cognitive

-Monoplegia

-Speech:

-Hemiplegia

-Aphasia

-Dysphasia

-Dysarthria

-Fluency disorder

1) If known or suspected, rather than TIA, document: -Vertebro-basilar artery syndrome -Carotid artery syndrome -Precerebral artery syndrome -Amaurosis fugax -Transient global amnesia -Other cerebral ischemic attacks and syndromes

1)Specify site: -Left or right cerebrum -Cerebellum -Brainstem -Epidural -Subdural -Subarachnoid

2) Specify if with LOC and for how long

1) Document: -Level of vertebral column, for example, L1 -Displaced versus nondisplaced -Part of vertebra fractured, for example, posterior arch

1) Document type of fracture, for example: -Type II dens fracture of the 2nd cervical vertebra -Type III spondylolisthesis of the 2nd cervical vertebra -Stable versus unstable burst fracture -Zone I-III or Type 1-4 sacral fracture

Documentation Requirements

1) Differentiate between removal of a portion or all of an intervertebral disc

1) Document: -Level of spinal column involved and -Number of vertebral joints fused

2) For operative approach, document: -Anterior approach, anterior column -Posterior approach, posterior column or -Posterior approach, anterior column

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