Brain Compression and Cerebral Edema

Did you know? “Midline shift” has no ICD-10 code to support severity metrics.

Consider Brain Compression and/or Cerebral Herniation when a midline shift is present. Also, document any Cerebral Edema independently to help support the Severity of Illness (SOI) and Risk of Mortality (ROM) of your patient. Cerebral edema is its own diagnosis (and is an MCC).

Brain Compression –
o  Cannot be coded from the radiologist’s report. Document in the clinical notes.
o “Midline shift” is a non-specific term, commonly used by radiologists. It has no ICD-10 code.
o “Midline shift with brain compression” is more specific—and AUDIT-PROOF.
o “Brain compression noted by effacement of cisterns, sulci, ventricles” is AUDIT-PROOF.

Cerebral Edema –
o Cannot be coded from the radiologist’s report. Document in the clinical notes.
o Is not inherent to strokes, tumors or trauma. When present, it should be documented in the progress note(s) and reiterated in the discharge summary. Document the treatment (steroids) used to independently treat it.

Download the complete tip, Brain Compression and Cerebral Edema.