the pediatric altered brain · appropriate code from subcategory p91.6, hypoxic ischemic...

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The Pediatric Altered Brain

Marietta Morhardt, BSN, RN, CPN, CCMClinical Documentation SpecialistChildren’s Hospital and Medical CenterOmaha, NE

Pam McCall, BSN, RN, CCM, CPNClinical Documentation SpecialistChildren’s Hospital and Medical CenterOmaha, NE

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Identify the differences between the pediatric and adult brain– Become more familiar with pediatric brain anomalies, including genetic, metabolic, and acquired; their sequelae; and general accompanying codes

– Learn about the pediatric version of the Glasgow Coma Scale in regard to supporting documentation of mentation in brain injury/trauma

– Identify the lift in SOI/ROM that can occur by more complete documentation of structural and functional brain abnormalities


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Children’s Hospital & Medical Center Fast Facts

• Children’s Hospital & Medical Center is the only full‐service pediatric healthcare center in Nebraska, providing expertise in more than 50 pediatric specialty services to children across a five‐state region and beyond.

• We are home to Nebraska’s only Level IV regional newborn intensive care unit and the state’s only Level II pediatric trauma center.

• Our regional heart center offers expertise in pediatric heart transplantation.• Children’s is recognized as a 2018–2019 Best Children’s Hospital by U.S. News & World Report

in five pediatric specialties: cardiology and heart surgery, pulmonology, gastroenterology & GI surgery, orthopedics, and diabetes & endocrine disorders.

• In 2017:– 623,700 total patient visits– 138,500 patients– 46,500 Medicaid patients– 50+ outpatient specialty services– 145 beds– 11 regional clinics in 3 states

childrensomaha.org


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The Great “Unknown”

• Almost every infant has potential for growth & development, but no one can accurately predict how much or how far a particular child can advance


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Infant Cranial Sutures

By Xxjamesxx ‐ Own work, CC BY‐SA 3.0, https://commons.wikimedia.orgw/index.php?curid=12055702


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Infant vs. Adult

https://en.wikipedia.org/wiki/Skull#/media/File:Sobo_1909_104.png https://en.wikipedia.org/wiki/Skull#/media/File:Human_skull_side_bones.svg


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Anatomic Differences Between Adult and Pediatric Nervous System and Skull

Adult Children

Mature nervous system Complete but immature nervous system

Head size proportionate to body Top heavy; head is large in proportion to body

Sutures are ossified by age 12 years Thin cranial bones are not well developed; unfused sutures

Brain is highly vascular with small subarachnoid spaces


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Lobes of the Brain

https://www.wpclipart.com/medical/anatomy/brain/brain_lobes_color_coded_and_labeled.png.html


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Cognitive Progression – Sensorimotor (0–2 Years)

• The infant explores the world through direct sensory and motor contact. Object permanence and separation anxiety develop during this stage.

Photo Courtesy of Pam McCall


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Cognitive Progression – Preoperational (2–6 Years)

• The child uses symbols (words and images) to represent objects but does not reason logically. The child also has the ability to pretend. During this stage, the child is egocentric.

Photo courtesy of Marietta Morhardt


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Cognitive Progression – Concrete Operational (6–12 Years)

• The child can think logically about concrete objects and can thus add and subtract. The child also understands conversation.



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Cognitive Progression – Formal Operational (12 Years–Adult)

• The adolescent can reason abstractly and thinks in hypothetical terms.



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Genetic & Congenital Disorders Affecting Brain & Development

• Trisomy 21 – Q90• Trisomy 13 & 18 – Q91• Microcephaly – Q02• Other brain malformations – Q04 (agenesis of corpus callosum, schizencephaly, etc.)

• Syndromes affecting multiple systems – Q87 (Goldenhar, Apert, VATER, Prader‐Willi, etc.)

• Karyotype disorders – Q96–Q99 (Turner’s, fragile X, etc.)


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Metabolic Syndromes Affecting Brain & Development

• PKU (phenylketonuria) – E70• Disorders of branched‐chain amino‐acid metabolism & fatty‐acid metabolism – E71 (maple syrup urine disease, carnitine deficiency, adrenoleukodystrophy, etc.)

• Mitochondrial disorders – E88 • Metal metabolism disorders – E83• Tay‐Sachs disease – E75.02• Batten’s disease – E75.4


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Encephalopathy – G93

Means “disorder of brain”

• Potentially treatable encephalopathy:– Hypoxic ischemic – if occurs at birth (HIE – P91.60), can be used throughout life if still relevant (Chapter

16 code)– Anoxic – G93.1– Toxic – G92 (poisonings, PRES [posterior reversible encephalopathy syndrome])– Metabolic – G93.41 (DKA, hypoglycemia, metabolic syndromes, renal failure)– Septic – G93.41 (make sure organism is identified, if known)– Hepatic – K72.90– Traumatic – G93.49* (no real assigned ICD‐10 code, need to code to specific injury; may need sequela

code if current injury) – Infectious – G04–G05 (includes ADEM, ADM; make sure organism is identified, if known)– Hypertensive – I67.4 (if cause of hypertension known, should be documented)

**Make sure to clarify acute vs. chronic**


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Neonatal EncephalopathyCoding Clinic, Fourth Quarter 2017

• Two new codes P91.811, Neonatal encephalopathy in disease classified elsewhere, and P91.819, Neonatal encephalopathy, unspecified, have been created to describe neonatal encephalopathy that is caused by some other condition as well as unspecified neonatal encephalopathy. Neonatal encephalopathy is a clinically defined syndrome of neurological dysfunction in the newborn infant, manifested by difficulty initiating and maintaining respiration, depression of tone and reflexes, subnormal level of consciousness and seizures. Typically, the condition affects full term newborns.

• When neonatal encephalopathy is caused by a significant hypoxic ischemic brain injury, it is called hypoxic ischemic encephalopathy [HIE], and assigned the appropriate code from subcategory P91.6, Hypoxic ischemic encephalopathy [HIE]. Current science has demonstrated that a newborn may meet the diagnostic criteria for HIE, but may have some other underlying cause, not associated with HIE. When assigning a code for neonatal encephalopathy, code first the underlying cause, if known.

© Copyright 1984‐2018, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.


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Encephalopathy (cont.)

• Unlikely to be fully corrected include:– Alcoholic – G31.2 (generally more adult population, but can be seen with teen patients)

– Ischemic (usually chronic from previous anoxic event)– Structural– Wernicke’s – E51.2

**Make sure to clarify acute vs. chronic**


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What About “Altered Mental Status”?

• Given that R41.82 is a Chapter 18 symptom code, given that the ICD‐10‐CM Official Guidelines for Coding and Reporting state that “Signs and symptoms that are associated routinely associated with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” and given that an altered mental status is integral to having an encephalopathy, I would only report G93.40.March 6, 2018 CDI Blog (Volume 11, Issue 47)

This question was answered by James S. Kennedy, MD, CCS, CDIP, CCDS, after the January 17, 2018, episode of ACDIS Radio. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at [email protected].


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Encephalopathy (cont.)

• Additional resources:– https://acdis.org/articles/guest‐post‐altered‐mental‐status‐remains‐challenge‐icd‐10‐cm‐%E2%80%93‐part‐2

– August 16, 2017 CDI Blog– https://acdis.org/articles/note‐acdis‐editor‐encephalopathy‐help‐confusing‐times?utm_source=silverpop&utm_medium=email&utm_campaign=ENL_180816_CDI_ECDIS%20(1)

– August 16, 2018 CDI Strategies (Volume 12, Issue 36)


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Case Study

• 11‐year‐old female admitted in DKA (diabetic ketoacidosis) with new onset Type 1 diabetes mellitus – E10.10

• Altered mental status – confused & less responsive is documented in H&P – R41.82

• MRI scan shows cerebral edema

What additional diagnoses would you use or query for?• Toxic encephalopathy – G92 – increases ROM to 2• Compression of brain – G93.5 – increases ROM to 3 and SOI to 3


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Case Study – 420 Diabetes – DKA


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Brain Compression

• Neoplasms• Trauma (hematomas, AVM bleeds, etc.)• Hydrocephalus• Infection/abscess


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Hematoma Locations


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Epidural Hematomas – S06.4X‐

• Requires linear force• Associated with skull fracture & torn artery• Brain often uninjured• “Lucid” interval is common• Common in accidental head injuries


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Subdural Hematomas – S06.5X‐

• Requires significant rotational force to occur• Associated with brain injury and torn bridging of veins• There are neurological symptoms from the start• Common in infants with abusive head trauma


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Concussion – S06.‐

• Important to know with/without LOC and duration• If there are other intracranial injuries will go to subcategories – S06.1‐, S06.6, etc.

• Document correct sequelae• Document cause, if known (also necessary for trauma registry)


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Glasgow Coma Scale

• The most common scoring system used to describe the level of consciousness in a person following brain/head injury

• It is used to help gauge the severity of an acute brain injury• It is simple, reliable, and correlates well with outcome following severe brain injury

• It is an objective way of recording the initial and subsequent level of consciousness


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Glasgow Coma Scale

• The Coma Scale codes (R40.2‐) can be used in conjunction with:– Traumatic brain injury codes– Acute cerebrovascular disease– Or sequelae of CV disease codes– Other non‐trauma conditions


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Glasgow Coma Scale

• Measurement:– Eyes open (never, to pain, to sound, spontaneous)– Best verbal response (none, incomprehensible words, inappropriate words, confused conversation, oriented)

– Best motor response (none, extension, abnormal, flexion withdrawal, localizes pain, obeys commands)


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Glasgow Coma Scale

• One code from each subcategory is needed to complete the scale• 7th character associated with each code indicates when the scale was recorded & should match for all three codes & be assessed at the same time


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Pediatric Glasgow Coma ScaleCoding Clinic, Fourth Quarter 2017Question:• Coma scale codes R40.2110–R40.2364 reflect various coma levels for eyes open, best verbal

and motor response. Our pediatric coma scores are based on auditory/visual stimuli, agitated, persistent cry, consolable, smiles, etc. How is verbal response for newborns through two years of age coded?

Answer:• Inclusion terms addressing pediatric Glasgow coma scale descriptions have been added to

codes for coma scale, best verbal response, and coma scale, best motor response. If these descriptions are documented in the medical record, the corresponding codes can be assigned without the specific score or numeric value being documented. If the provider's documentation clearly shows that the ratings are specific scores or numeric values for the Glasgow coma scale, it would be appropriate to report codes from subcategories R40.21‐, R40.22‐ and R40.23‐. These codes are used when the individual score(s) or numeric values are documented within the health record.



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Pediatric Glasgow Coma ScaleCoding Clinic, Fourth Quarter 2017

• The following new inclusion terms are provided at the corresponding codes from subcategory R40.23, Coma scale, best motor response, for newborns and children through 5 years of age:– R40.232, Coma scale, best motor response, extension

Abnormal extensor posturing to pain or noxious stimuli (< 2 years of age)Extensor posturing to pain or noxious stimuli (2–5 years of age)

– R40.233, Coma scale, best motor response, abnormalflexure posturing to pain or noxious stimuli (0–5 years of age)Flexion/decorticate posturing (< 2 years of age)

– R40.234, Coma scale, best motor response, flexion withdrawalWithdraws from pain or noxious stimuli (0–5 years of age)

– R40.235, Coma scale, best motor response, localizes painLocalizes pain (2–5 years of age)Withdraws to touch (< 2 years of age)

– R40.236, Coma scale, best motor response, obeys commandsNormal or spontaneous movement (< 2 years of age)Obeys commands (2–5 years of age)


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Brain Tumor Codes

• “Malignant Neoplasm of Brain” – C71.‐• Tumors code by location:

– Frontal lobe– Temporal lobe– Parietal lobe– Occipital lobe– Cerebral ventricle– Cerebellum– Brain stem– Overlapping sites of brain– Brain, unspecified


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Brain Tumor Locales

Supratentorial ependymona

Pinealoma

Medulloblastoma

Cerebellar astrocytoma

Intratentorial ependymona

Brainstem glioma

Craniopharyngioma

Optic glioma

Astrocytoma

https://commons.wikimedia.org/wiki/File:PSM_V46_D168_Mesial_view_of_the_human_brain.jpg


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Anatomical Brain Disorders

• Microcephaly – Q02• Anencephaly – Q00.0• Dysgenesis or agenesis of corpus callosum – Q04.0• Schizencephaly – Q04.6• Arnold‐Chiari malformation – Q07

**These do not necessarily mean intelligence is affected; however, in many cases, it is**


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Chronic Seizure Disorders

• Lennox‐Gastaut syndrome – G40.818• Tuberous sclerosis – Q85.1• Infantile spasms – G40.82• Rett’s syndrome – F84.2


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General Seizure Types – G40.‐

• “Grand mal” or generalized tonic‐clonic: Unconsciousness, convulsions, muscle rigidity

• Absence: Brief loss of consciousness• Myoclonic: Sporadic (isolated), jerking movements• Clonic: Repetitive, jerking movements• Tonic: Muscle stiffness, rigidity• Atonic: Loss of muscle tone

**Codes require a 6th character: • 1: With status epilepticus (continuous seizures)• 9: Without status epilepticus


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Coding Clinic, Fourth Quarter 2013

Question:• Should encephalopathy be reported as an additional diagnosis with seizure when it is due to a postictal state? Would the encephalopathy be considered inherent to the seizure, or can it be reported separately?


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Coding Clinic, Fourth Quarter 2013 (cont.)

Answer:• When documentation indicates that encephalopathy is due to the postictal state of seizure, it is considered inherent to the seizure and should not be coded separately.

• Postictal state of a seizure is a transient deficit that occurs between the end of an epileptic seizure and the patient’s return to baseline. This period of decreased functioning in the postictal period usually lasts less than 48 hours. Therefore, the encephalopathy is integral to the condition.



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Intellectual Disability

• Question always posed: How can I measure without a neuro‐psych/IQ test?


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ICD‐10 Codes & Approximate Definitions

• Mild intellectual disability – F70– Affected children usually exhibit both expressive and receptive verbal skills and are able to learn some social skills. – They can usually be expected to care for themselves as adults, with some guidance.

• Moderate intellectual disability – F71 – This group of children may be able to learn some expressive and receptive speech, but usually have poor social skills

and those are often delayed, along with their achievement of learning activities of daily living. Their highest education level is usually elementary school level. They usually meet early motor milestones within the normal range.

– When reaching adulthood, they will generally need complete supervision, often in a group setting. They may be capable of unskilled occupations in a supported‐employment setting.

• Severe intellectual disability – F72– Children with severe and profound intellectual disability are often diagnosed very early because acquisition of even

the earliest motor milestones is delayed. – Affected children have limited speech and ability to learn a few self‐help skills, and will need a protected environment

as an adult. A living situation in a group home with increased support will generally be possible. • Profound intellectual disability – F73

– Affected children will generally need full care as adults, often in a nursing home environment. They are almost always nonverbal & have limited ability to communicate needs to others.


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Case Study

• 10‐year‐old admitted for chemo – Z51.11• ALL (Acute lymphoblastic leukemia) in remission – C91.01• Autism – F84.0 • Infusaport® – Z95.828


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Why Would You Query for Intellectual Disability?

A. To show an accurate medical picture of the patientB. To increase SOI (severity of illness) or ROM (risk of mortality)C. Because all patients with autism have intellectual disabilityD. Both A and B

ANSWER: D – Documentation of intellectual disability shows an accurate medical picture of the patient. It increases SOI and also increases ALOS (average length of stay) and reimbursement.


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Case Study – DRG 695 Chemotherapy for Acute Leukemia

Coding ROM SOI ALOS Weight Reimbursement

Autism without

intellectual disability

documented

1 2 4.01 0.8886 $9,516.36

Autism & moderate intellectual disability

documented

1 3 8.79 2.3161 $24,210.35


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Autism – F84.0

• Includes:– Autism spectrum disorder– Infantile autism– Infantile psychosis– Kanner’s syndrome– Asperger’s syndrome – F84.5– Atypical autism – F84.9


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Scholastic Skill Disorders – F81

• Developmental dyslexia• Mathematics disorders• Writing disorders


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Developmental Disorders of Speech & Language – F80.‐

• Phonological disorders• Expressive language• Mixed receptive‐expressive language• Language delay due to hearing loss (also code hearing loss)• Other


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Behavioral & Emotional Disorders

• ADHD – F90.‐• Conduct disorders – F91.‐ (includes oppositional defiant disorder)• Social functioning – F94.‐ (includes various attachment disorders)• Tic disorders – F95.‐ (Tourette’s, etc.)


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Mood Affective Disorders

• Depression – F30–F39 (major episode: distinguish between single or recurrent & mild, moderate or severe [with or without psychotic symptoms])

• Anxiety disorders – F40–F41• Obsessive‐compulsive disorders – F42.‐• Reaction to severe stress disorders – F43 (includes PTSD, acute stress reaction, & adjustment disorders)

• Dissociative & conversion disorders – F44.‐


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“Paint the picture of your patient with words, so the coder can paint the same picture with codes.” –Robert S. Gold, MD

https://cdn.pixabay.com/photo/2016/01/14/17/56/rainbow‐1140420__340.jpg


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Thank you. Questions?

[email protected]@childrensomaha.org

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the pediatric altered brain · appropriate code from subcategory p91.6, hypoxic ischemic...

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