Guide to Clinical Validation,
Documentation and Coding
Contents
Introduction ......................................................................................................... 1
Diagnoses ............................................................................................................. 7
Acidosis ..................................................................................................................................... 7
Acute Exacerbation ..............................................................................................................13
Acute Exacerbation/Decompensation of Chronic Obstructive Pulmonary
Disease, Emphysema with Bronchitis and Asthma with COPD .................................13
Acute Kidney Injury ..............................................................................................................17
Acute Myocardial Infarction ...............................................................................................23
Acute Pulmonary Edema, Noncardiogenic ...................................................................28
AIDS ..........................................................................................................................................32
Aspiration Pneumonia/Pneumonitis/Bronchitis ...........................................................39
Atelectasis ...............................................................................................................................46
Bacteremia ..............................................................................................................................49
Candidiasis ..............................................................................................................................54
Cerebral Edema .....................................................................................................................59
Cerebrovascular Accident ...................................................................................................64
Chest Pain as Principal Diagnosis .....................................................................................72
Coagulopathy ........................................................................................................................76
Decubitus (Pressure) Ulcer .................................................................................................81
Deep Vein Thrombosis of Upper and Lower Extremities ............................................85
Dehydration as Principal Diagnosis ..................................................................................89
Empyema, Pleural or Pyothorax ........................................................................................93
Encephalopathy ....................................................................................................................97
Gastrointestinal Hemorrhage ......................................................................................... 101
Heart Failure (non-rheumatic) ........................................................................................ 108
Hepatic Encephalopathy/Hepatic Coma/Portosystemic Encephalopathy .......... 113
Hypernatremia ................................................................................................................... 116
Hyponatremia ..................................................................................................................... 120
Iatrogenic (Intraoperative) Puncture or Laceration (Tear) (Rent) ......................... 126
Ileus ....................................................................................................................................... 130
Intraop or Postop Hematoma/Hemorrhage/Seroma (not due to device,
implant or graft) ........................................................................................................ 133
Intravenous/Dialysis Line/Catheter Infections ........................................................... 138
Malnutrition ........................................................................................................................ 143
Overdose, Poisoning, and Toxic Effects of Illicit Drugs, Prescribed Drugs,
Nonprescribed Drugs, Alcohol and Solvents, Gases, Aerosols, Nitrates ..... 147
Pleural Effusion ................................................................................................................... 152
Postoperative Anemia ...................................................................................................... 157
Postoperative (Postprocedural) (Wound) Infection .................................................. 161
iii
Guide to Clinical Validation, Documentation and Coding
Cerebral Edema
Cerebral Edema
G93.6
Cerebral edema
MCC
S06.1X0A
Traumatic cerebral edema without loss of consciousness, initial encounter
MCC
S06.1X[1,2,3,4]A
Traumatic cerebral edema with loss of consciousness of [30 min or less,
31 min to 59 min, 1 hour to 5 hours 59 min, 6 hours to 24 hours], initial
encounter
MCC
S06.1X5A
Traumatic cerebral edema with loss of consciousness greater than
24 hours with return to pre-existing conscious level, initial encounter
MCC
S06.1X6A
Traumatic cerebral edema with loss of consciousness greater than 24 hours
without return to pre-existing conscious level with patient surviving,
initial encounter
MCC
S06.1X7A
Traumatic cerebral edema with loss of consciousness of any duration with MCC
death due to brain injury prior to regaining consciousness, initial encounter
S06.1X8A
Traumatic cerebral edema with loss of consciousness of any duration with MCC
death due to other cause prior to regaining consciousness, initial encounter
S06.1X9A
Traumatic cerebral edema with loss of consciousness of unspecified
duration, initial encounter
Diagnosis:
MCC
cerebral edema; traumatic cerebral edema
Discussion
Cerebral (brain) edema is the excess collection of fluid and sodium in the brain. It may result in
brain swelling which leads to elevated intracranial pressure (ICP) and compression, which
displaces or herniates the brain tissue from one area to another with “a mass effect/midline
shift.” Its clinical significance ranges from none/low to being an independent risk factor for
mortality. The causes of cerebral edema are varied and include cerebral
infarction/hemorrhage/ischemia, trauma, neoplasm, infection, toxicity, or metabolic disorders
affecting the nervous system.
The clinical significance of the cerebral edema must be stated and is the determining factor for
reporting. If the edema is clinically insignificant (i.e., expected [postsurgery]), small,
asymptomatic and resolves spontaneously without treatment, without further workup or
monitoring, then it will not be reported. If it is symptomatic, requires workup, monitoring,
treatment or causing further complications (neurological symptoms, herniation), it can be
reported as long as the link is made to the clinical criteria and its significance stated. When
reportable, cerebral edema, as a manifestation of the underlying condition or as a concurrent
condition to traumatic brain injury, is a reflection of the condition having a higher severity of
illness and risk of mortality than if the cerebral edema was inconsequential. When the clinical
significance is unclear or there is contradictory information or incomplete documentation,
query the attending physician or other qualified health care professional.
Coding Tip
Code assignment cannot be based only on ancillary test results or therapies alone. A
diagnosis and its clinical significance must be supported by both physician or other
qualified health care professional documentation and clinical criteria. When it is
unclear or there is contradictory information, query the physician or other qualified
health care professional for clarification.
59
Procedures
Bone Marrow/Stem Cell Transplant
Administration—Transfusion. Putting in blood or blood products.
302
Administration, Circulatory, Transfusion
Procedure:
bone marrow or stem cell transplant (infusion)
Discussion
Although the actual procedural statement indicates transplant, a bone marrow or stem cell
transplant is actually a transfusion procedure, by PCS definition and coded in section 3
Administration to the root operation 2 Transfusion.
Administration procedures should not be confused with Transplantation procedures. Instilling
autologous or nonautologous bone marrow or stem cells is coded to Administration, whereas
implanting a functioning, living body part from another individual is coded to the root
operation Transplantation in the Medical and Surgical section (0).
Coding Guideline B3.16: Transplantation vs. Administration
Putting in a mature and functioning living body part taken from another individual or animal is
coded to the root operation Transplantation. Putting in autologous or nonautologous cells is
coded to the Administration section.
Bone marrow or peripheral blood stem cell transplantation is a process that includes
mobilization, harvesting, and transplant of bone marrow or peripheral blood stem cells and
the administration of high-dose chemotherapy or radiotherapy prior to the actual transplant.
The bone marrow or peripheral stem cells are harvested from either a patient’s (autologous) or
donor’s (allogeneic) bone marrow or peripheral blood for intravenous infusion.
Harvested bone marrow is usually obtained from a large bone of the donor. The donor is given
general or regional anesthesia. Needles are inserted through the skin over the pelvic (hip) bone
and into the bone marrow to draw the marrow out of the bone. The harvested bone marrow is
then processed to remove blood and bone fragments. Harvested bone marrow may be
cryopreserved. Purging is a process to remove certain types of cells, such as cancer cells and
T-lymphocytes, from stem cells prior to infusion. After the bone marrow is processed, the
processed marrow is infused into the bloodstream of the recipient through an intravenous
catheter.
Hematopoietic stem cells are found in the bone marrow, in the bloodstream (peripheral blood
stem cells) and in umbilical cord blood. Cells from each of these sources may be used in
transplants.
An autologous transplant uses the patient’s own bone marrow or stem cells for the transplant,
while an allogeneic transplant uses a donor’s bone marrow or stem cells. For stem cell
harvesting from peripheral blood, the progenitor cells are collected by apheresis, often after
the donor is given a hematopoietic growth factor to mobilize progenitor cells into the
bloodstream. The patient is prepared in much the same way as when giving a regular blood
donation. Whole blood is drawn out of one arm and put into an instrument called a cell
205
Appendix A. Query Guidelines, Examples, and Template
Guide to Clinical Validation, Documentation and Coding
Cerebral Edema Example
Please review the following documentation/clinical data: (Enter the pertinent information from the documentation in the
medical record.)
cerebral infarction
Reference coding guideline or clinical criteria: (Enter the appropriate references to be cited.)
Increasing vasogenic cerebral edema causing mass effect noted on follow-up CT scan.
Based on this information, please clarify:
Was the finding of cerebral edema causing mass effect of any clinical significance, and if so, can it be described?
Can the result of the mass effect be further defined (increasing intracranial pressure, brain herniation, other
(specify), or unknown)?
Physician response or supporting documentation:
Physician signature and date:
Amendment to the medical record is required:
If yes, please amend the following documents:
Clinical coder/clinical documentation improvement:
Phone:
Email:
246
❑ yes
❑ no