ICD-10-CM expands coding for nontraumatic brain hemorrhages
by Lolita M. Jones, RHIA, CCS
ICD-10-CM will improve the reporting of clinical data for numerous diseases and conditions, including nontraumatic brain hemorrhages.
In ICD-9-CM, there are just five codes available for nontraumatic brain hemorrhages:
- 430 (subarachnoid hemorrhage)
- 431 (intracerebral hemorrhage)
- 432.0 (nontraumatic extradural hemorrhage)
- 432.1 (subdural hemorrhage)
- 432.9 (unspecified intracranial hemorrhage)
However on October 1, 2013, when ICD-10-CM/PCS takes effect, there will be 35 ICD-10-CM codes available for nontraumatic brain hemorrhages. Click here to access a table listing the new codes.
The expansion of the coding and classification for nontraumatic brain hemorrhages will require more detailed documentation from physicians. They will need to document the location/origin of the hemorrhage for correct assignment of the nontraumatic subarachnoid and intracerebral hemorrhage codes. In addition, they will need to document the severity (acute, subacute, chronic) of the hemorrhage for the correct assignment of the subdural hemorrhage codes.
These expanded codes will also require inpatient coders to strengthen their clinical knowledge of nontraumatic brain hemorrhages to accurately review the medical record and assign the appropriate codes.
Nontraumatic subarachnoid hemorrhage
Common causes. ICD-10-CM codes in categories I60.00–I60.9 classify nontraumatic subarachnoid hemorrhage (SAH). According to the Handbook of Clinical Neurology, Volume 93 (Third series), Stroke Part II: Clinical Manifestations and Pathogenesis, by Michael E. Kelly, Robert Dodd, and Gary K. Steinberg, causes of SAH include the following:
- An aneurysm that is spontaneous or due to infection or hereditary diseases, such as autosomal dominant polycystic kidney disease (ADPKD), Ehlers-Danlos syndrome type IV, or neurofibromatosis type I
- Perimesencephalic hemorrhage (the origin of the blood is unknown, and the blood is limited to an area in the subarachnoid space around the midbrain, the mesencephalon)
- Vertebral artery dissection
- Dural arteriovenous fistulas
- Cervical spinal arteriovenous malformations
- Cervical spinal tumors (e.g., hemangioblastoma)
High-risk factors. There is an increased risk for developing a SAH in first-degree family members of patients with a SAH. Women are more prone to SAH caused by aneurysms of the internal carotid artery, men are more prone to SAH caused by aneursyms of the anterior communicating artery, according to the Handbook of Clinical Neurology, Volume 93 (Third series), Stroke Part II: Clinical Manifestations and Pathogenesis.
Common clinical features. People with SAHs often experience headaches (sudden, severe, and excruciating), nausea, vomiting, loss of consciousness, neck stiffness, photophobia, and ocular hemorrhages, as seen on a fundoscopic exam.
Diagnostics. A high-resolution noncontrast CT scan can assess the location and extent of aneurysmal SAH. Physicians also use lumbar puncture, cerebral angiography, magnetic resonance imaging (MRI), magnetic resonance angiography, and CT angiography as diagnostic tools.
Treatment. Physicians may treat a ruptured cerebral aneurysm SAH with a craniotomy with aneurysmal clipping or an endovascular coil embolization.
Clinical coding tip. The ICD-10-CM diagnosis codes in categories I60.00–I60.02 classify the carotid siphon and bifurcation as the location/origin of the hemorrhage. The internal carotid artery pathway has several regions:
- Intrathoracic origin
- Carotid bifurcation
- Carotid siphon
- Ophthalmic artery
“The carotid siphon is the second most common location for cerebrovascular atherosclerotic disease,” according to Essential Practice of Surgery, Basic Science and Clinical Evidence, a book edited by Jeffrey A. Norton, R. Randall Bollinger, Alfred E.Chang, Stephen F. Lowry, Sean J. Mulvihill, Harvey I. Pass, and Robert W. Thompson.
Nontraumatic intracerebral hemorrhage
Common causes. ICD-10-CM codes in categories I61.0–I61.9 classify nontraumatic intracerebral hemorrhage (ICH). According to Neurological and Neurosurgical Intensive Care, Fourth Edition, by Allan H. Ropper, Daryl R. Gress, Michael N. Diringer, Deborah M. Green, Stephan A. Mayer, and Thomas P. Bleck, causes of ICH include:
- Vascular malformation
- Amyloid angiopathy
- Abnormal coagulation
- Use of anticoagulants or thrombolytics
- Heavy alcohol use
- Sympathomimetic drugs (e.g., cocaine, amphetamines, pseudoephedrine, or phenylpropanolamine)
- Hemorrhagic infarction
- Venous occlusion
High-risk factors. According to Neurological and Neurosurgical Intensive Care, Fourth Edition, there is an increased risk of developing ICHs in patients who experience reperfusion (e.g., after recanalization of an occluded vessel) or who are in the postoperative period after a carotid endarectomy.
Common clinical features. People who develop ICHs commonly experience headaches, nausea, vomiting, acute hypertension, diminished level of consciousness (critical for prognosis and medical management of patient), pupillary enlargement, or brain edema (i.e., swelling).
Diagnostics. A clinical assessment may reveal the common clinical features listed above, but a physician uses a CT scan to confirm the diagnosis and assess the size of the blood clot. A physician may use an angiography to identify underlying vascular abnormalities (e.g., arteriovenous malformation). An MRI can be useful when a physician cannot see a vascular malformation with angiography.
Treatment. The location, size, and etiology determine how the physician will manage the hemorrhage. For example, the larger the hemorrhage, the greater the patient’s impairment of consciousness is. Note that the relationship between the location of the hemorrhage and the treatment may be one of the reasons why location is a component of the ICD-10-CM codes. ICH management can range from observation (e.g., intracranial pressure monitoring) to aggressive medical therapy (e.g., lowering blood pressure) to surgical intervention (e.g., drainage of clot, removal of arteriovenous malformation, or craniotomy). Surgical interventions are not always the first treatment of choice because physicians don’t want to damage normal brain tissue when treating a hemorrhage, putting the patient at risk for death or permanent disability.
Nontraumatic subdural hemorrhage
ICD-10-CM codes in categories I62.00–I62.03 classify nontraumatic subdural hemorrhage (SDH). A subdural hemorrhage or hematoma is a collection of blood between the dura and the brain. The blood appears in the areas between the dura mater and the arachnoid, where there is normally a thin cushion of fluid.
Common causes. According to Essential Forensic Neuropathology, by Juan C. Troncoso, Ana Rubio, and David R. Fowler, common causes of SDHs include:
- Arterial bleeding (e.g., ruptured saccular aneurysm or arteriovenous malformation)
- Spontaneous intracranial hypotension
- Status post procedures with potential to cause a cerebrospinal fluid leak (e.g., spinal puncture or anesthesia)
According to Encyclopedia of the Human Brain by Vilanayur Ramachandran, common causes also include:
- Stimulant abuse
High-risk factors. Patients with the following are at a higher risk for developing SDHs, according to Essential Forensic Neuropathology:
- Severe brain atrophy because increased tearing is likely due to stretched vessels bridging the dura and brain; even a minor trauma such as sneezing can cause tearing
- Anticoagulant therapy and severe brain atrophy
- Arachnoid cysts
- Hematopoietic stem-cell transplantation
Oral contraceptive use, smoking, and hypertension also put people at a higher risk for SHDs, according to Encyclopedia of the Human Brain.
Common clinical features. Patients with SDH often experience sudden, severe headaches. Less common is the transient or persistent loss of consciousness, vomiting, and seizure activity, fever, and stiff neck.
Diagnostics. Physicians may employ CT imaging or lumbar punctures to examine the cerebrospinal fluid for blood. “After the SDH is diagnosed, cerebral angiography may be performed to identify the responsible vascular lesion, search for other lesions (if multiple aneurysms are present), and to assist in operative management,” according to Encyclopedia of the Human Brain.
Treatment. For treatment, physicians usually focus on addressing the symptoms or preventing secondary complications with analgesics, antiemetics, or sedatives. Anticonvulsives may be necessary if seizures occur. If an aneurysm is present, physicians usually perform a surgical clipping at the neck of the aneurysm.
Clinical coding tips. The ICD-10-CM diagnosis codes in categories I62.00–I62.03 classify the acuity of the SDH, and acuity depends on the size of the affected vessel and the amount of bleeding, according to Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, by Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle, and Kerry H. Cheever. Acute SDH is present within the first 48 hours of symptoms/clinical features There is freshly coagulated blood with no or minimal attachment to the dura. Subacute or chronic SDH is present when the blood clot becomes more adherent to the dura (i.e., more adherent than the first 48 hours), according to Essential Forensic Neuropathology.
Nontraumatic extradural hemorrhage/spinal epidural hemorrhage
ICD-10-CM code I62.1 classifies nontraumatic extradural hemorrhage. This type of hemorrhage is included in the spinal epidural hematoma (SEH) family, which comprises a group of disorders that result in the accumulation of blood in the spinal epidural space.
Common causes. All of the following are common causes of nontraumatic extradural hemorrhages, according to an article by The New York School of Regional Anesthesia (NYSORA), “Diagnosis and Management of Intraspinal, Epidural, and Peripheral Nerve Hematoma”:
- Lumbar puncture
- Epidural or spinal anesthesia
- Interventional spine procedures or surgeries
- Coagulopathy or bleeding diathesis
- Hepatic diseases with portal hypertension
- Vascular malformation
- Disk herniation
- Paget disease of the vertebral bones
- Valsalva maneuver
High-risk factors. SEH is more prevalent in females than in males. “Lumbar puncture or epidural anesthesia should be avoided in individuals who are on anticoagulant therapy, following thrombolysis, or when a bleeding diathesis is suspected,” according to NYSORA’s article.
Common clinical features. Patients with SEH often experience constant back pain that is severe and localized, and mimics an acute disc herniation if the pain is radicular in nature. People with SEH may also experience weakness, numbness, or urinary or fecal incontinence.
Diagnostics. A complete blood count with platelets may help to assess the level of bleeding and detect any infection. A spinal MRI can provide the location and extent of the hematoma, identify any associated vascular malformation, and assess the degree of cord compression.
Treatment. The degree of spinal cord compression may affect a physician’s decision to provide conservative management (i.e., observation only) or to intervene surgically (e.g., laminectomy with evacuation of the hematoma).
Sequelae of nontraumatic brain hemorrhages
ICD-10-CM provides separate codes for the sequelae or late effect of nontraumatic brain hemorrhages. A late effect is the residual effect (i.e., condition produced) after the acute phase of an illness or injury has terminated. In ICD-10-CM (just as in ICD-9-CM), there is no time limit on when a late effect code can be used. The residual effect may be apparent early or it may occur months or years later. Note the following ICD-10-CM subcategories:
- I69.00–I69.09 classifies the sequelae of nontraumatic subarachnoid hemorrhage
- I69.10–I69.19 classifies the sequelae of nontraumatic intracerebral hemorrhage
- I69.20–I69.29 classifies the sequelae of nontraumatic intracranial hemorrhage
Coding tip. Coders may assign ICD-10-CM codes from category I69 with codes from I60–I67 when the medical record states the patient has a current cerebrovascular accident (CVA) and deficits from an old CVA.
Editor’s note: Jones is the principal of Lolita M. Jones Consulting Services in Fort Washington, MD, and an ICD-10-CM/PCS trainer approved by the American Health Information Management Association. She is also author of ICD-10-CM/PCS Implementation Action Plan. Visit her website at www.EZMedEd.com.