Consider a patient who is on your census in the medical ICU of a large tertiary center. The admitting or principal diagnosis is “non-traumatic intracerebral hemorrhage.” The patient’s wife found him unresponsive on the living room floor on April 6 and called 911. The patient has a history of hypertension, and his wife states that the patient “always forgot to take his medications.” A CT scan and MRI confirm an intracerebral hemorrhage with evidence of a midline shift. Upon arrival at the emergency department (ED), the Glasgow coma score total was 8 (eye 2, verbal 2, motor 4). One day later, the score is 3 (eye 1, verbal 1, motor 1). On April 7th, the doctor’s notes show orders of IV steroids and new surgical evacuation of the hemorrhage to “reduce intracranial pressure. The patient requires emergency surgery for evacuation of the intracerebral bleed. When deciding to query for the additional diagnosis of “compression of the brain” consider that the size of the skull is finite– it cannot expand to allow the uninjured brain tissue to “get out of the way” of the hemorrhage, which is increasingly taking up space. As the hemorrhage progresses, brain tissue is compressed against the rigid skull because it has nowhere to go. Documentation of “midline shift” indicates the brain tissue is shifting across the hemispheric midline. Not every patient with a subarachnoid hemorrhage needs surgical intervention. Physicians may monitor and treat small hemorrhages only with medication, so a diagnosis is needed to explain why this patient required additional resources. Currently, the ICD-10-CM code I61 is available for reporting non-traumatic intracerebral hemorrhages. This code can then further specify the location(s) if the intracerebral hemorrhages but does not include or incorporate additional conditions, such as cerebral compression or cerebral edema. Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial encounter in the ICD-10-CM code set is S06.360A, a different code. Coders should also report a code for the specific injury when possible. This situation represents a query opportunity. Step 03. In a document on your computer, example of a Leading and a Non-leading query to request additional information for the patient history that satisfies coding requirements. Step 04. Select the assignment link below and attach your completed assignment as a document (Word.doc(x), Adobe.pdf, Text.txt). Instructor Feedback and Grading Criteria Instructor feedback will be provided in comments on your assignment. You are encouraged to compare notes and ideas with your fellow students on this topic before submitting your assignment, although this is not required. You are welcome to use the Class Discussions, Course Questions, and Suggestions forum if you like. Please upload your assignment in a compatible format (for example, Word.doc(x), Adobe.pdf, Text.txt).
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