Alternate Level of Care, Neurology

HS317b – Coding & Classification of Health Data

Alternate level of care

Mandatory to record ALC via service transfer area in DAD in all provinces

Designed to separate statistics for true acute care patients from those non-acute patients occupying acute care beds

ALC days removed from DAD before national length of stay norms are established.

Standardize data collection

Has the patient finished the acute care phase of

his/her treatment but remains in the acute care bed?

Awaiting placement (extended care facility, hospice, residential care home, community services, etc).

No respite care available.

Diagnosis type W

Diagnosis

Z50.1 Other physical therapy Z51.5 Palliative care Z54.~ Convalescence Z59.~ Problems related to housing and

economic circumstances Z60.2 Living alone

Diagnosis

Z74.2Need for assistance at home and no other household member able to render care

Z75.~ Problems related to medical facilities and other health care

Z76.1Health supervision and care of foundling Z76.2Health supervision and care of other

healthy infant and child

Strokes

WHO defines stroke as “rapidly developing clinical signs of focal (at times global) disturbances of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin.”

Infarction (ischemic or embolic stroke) or hemorrhage (site & vascular origin of blood)

Transient Ischemia Attack (TIA)

TIA is a focal neurological deficit lasting less than 24 hours.

Mutually exclusive:G45.9 (TIA) cannot be coded in same episode

with Stroke range I60-I64

Coding Challenge

Terminology: cerebrovascular accident, CVA, Stroke Review Magnetic Resonance Imaging (MRI) or

Computerized Axial Tomography, (CAT or CT Scan). Cerebral angiograms with dye

Review Physician documentation for neurologic tests to determine functional deficits

Apply specificity coding standard

Excludes/Includes I60-I69

IncludesWith mention of HTN in I10 or I15Use additional code to identify presence of

HTN Excludes

TIATraumatic intracranial hemorrhage (S06.~)Vascular dementia (F01.~)

Hypertension typing

“it is of clinical importance that strokes in the presence of hypertension be captured, as HTN is implicated in conditions in many body systems and is also a stroke risk factor that can be medically controlled to a certain extent. The hypertension code is captured as diagnosis type 3”

Case History HTN Typing

(M)I63.4 Cerebral infarction due to embolism of cerebral arteries

(1) I10.0 Benign Hypertension (3) R47.0 Dysphasia & aphasia (3) G51.0 Bell’s palsy

Rationale for HTN as type 1 is that HTN was a problem during admission and was stabilized with IV Labetalol, therefore it warrants the selection of type 1.

Current Stroke vs Old Stroke

The stroke is considered to be a current condition (I60-I68) during the initial episode of care for the stroke

which includes both the acute care hospitalization and any subsequent transfer for rehabilitation to another facility to continue treatment of the associated neurological deficits

Current Stroke vs Old Stroke

Stroke is considered to be an old event when there is no longer any neurological

deficits present (can use Z86.7 Personal history of…)

There still remains a residual effect from the stroke—which has been previously treated—that continues to contribute to another disease process or continuing neurological deficit.

Hemorrhage Strokes

Subarachnoid hemorrhage (I60) Rupture of cerebral aneurysm or arteriovenous

malformation within the brain

Intracerebral hemorrhage (I61 or I62) Hemorrhage occurs beneath the cerebral cortex

This area is responsible for higher brain functions, including sensation, voluntary muscle movement, thought, reasoning and memory

Cerebral Infarction I63

Thrombosis versus EmbolismThrombosis - clot/thrombus forms within the

brain blocking the flow of blood.Embolism - a clot from elsewhere in the

circulatory system breaks free and travels through the circulatory system, becoming lodged in an artery supplying the brain.

Extension of Stroke

Extension of a cerebral infarction or stroke must be coded as another stroke or cerebral infarction. If it occurred during same episode of care

apply diagnosis type 2

Sequelae & Postop Strokes

Sequelae (I69) (late effect) indicate conditions in I60-I67 as the cause of a sequelae, themselves classified elsewhere (Sequelae Dx cannot be ‘M’)

Postop-stroke code from I60-I67 is coded with external cause based on time of occurrence.

Neurological Deficits

Neurological deficits:Paralysis, dysphagia, aphasia, urinary

incontinence and fecal incontinence All neurological deficits affecting the

management and treatment of the patient during the acute phase of the condition may be coded as a comorbid condition

Criteria for R13, R15 or R32

R13 Dysphagia – Dx type 1 if requiring nasogastric tube/enteral feeding If still requiring treatment more than 7 days

after the stroke occurred

Criteria for R13, R15 or R32

R15 Faecal incontinence-Dx type 1 If still present at discharge or persists for at

least 7 days R32 Unspecified urinary incontinence – Dx

type 1 If still present at discharge or persists for at

least 7 days

G46.~ Vascular Syndromes Following Stroke

G46.~ used when certain constellations of signs and symptoms are documented in the chart as due to a hemorrhage or infarct affecting particular areas of the brain.

When it is the result of a stroke, codes in the range I60-I67 † become dagger codes and G46.~*

Example

Patient admitted with a constellation of neurological deficits in a documented brain stem thrombosis and infarction, leading to a diagnosis of Weber’s syndrome

(M) 163.3 † Cerebral Infarction due to thrombosis of cerebral arteries

(3) G46.3* Brain stem stroke syndrome (includes: Weber’s Syndrome)

Classification based on MRDx

MCC 1 Diseases and Disorders of the Nervous SystemCMG 13 Specific cerebrovascular disorders

Medical includes SAH, ICH, SDH, stroke NOS With surgery, i.e. Drainage of SDH CMG 1

Craniotomy procedures