Did you know? Many of the clinical findings seen on CT scans of the head have specific ICD coding language necessary for you to accurately report the severity of illness of your patients.
- “Midline Shift” is more appropriately labeled as Brain Compression
- “Effacement of cisterns” is more accurately described as Brainstem Herniation
- “Traumatic Brain Injury” is more precisely defined as Diffuse Axonal Injury
- Cerebral Edema should always be documented in the medical record when it is seen on a CT scan or MRI
Please consider these diagnoses in patients who are being treated with systemic steroids, Mannitol infusions, burr holes, mechanical hyperventilation, frequent neuro checks by nursing, serial CNS imaging, etc.
Please don’t forget to document and address these findings in patients who are admitted for traumas, strokes or intracranial hemorrhages, and primary or secondary CNS malignancies.
Download the complete tip, Intracranial Abnormality.