Alternate Level of Care, Neurology

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Alternate Level of Care, Neurology

• HS317b Coding Classification of Health Data

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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

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• 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

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Diagnosis

• Z50.1 Other physical therapy
• Z51.5 Palliative care
• Z54. Convalescence
• Z59. Problems related to housing and economic
  circumstances
• Z60.2 Living alone

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Diagnosis

• Z74.2 Need for assistance at home and no other
  household member able to render care
• Z75. Problems related to medical facilities and
  other health care
• Z76.1 Health supervision and care of foundling
• Z76.2 Health supervision and care of other
  healthy infant and child

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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)

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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

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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

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Excludes/Includes I60-I69

• Includes
• With mention of HTN in I10 or I15
• Use additional code to identify presence of HTN
• Excludes
• TIA
• Traumatic intracranial hemorrhage (S06.)
• Vascular dementia (F01.)

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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

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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 Bells 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.

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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

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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
  strokewhich has been previously treatedthat
  continues to contribute to another disease
  process or continuing neurological deficit.

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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

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Cerebral Infarction I63

• Thrombosis versus Embolism
• Thrombosis - 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.

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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

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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.

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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

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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

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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

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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.

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Example

• Patient admitted with a constellation of
  neurological deficits in a documented brain stem
  thrombosis and infarction, leading to a diagnosis
  of Webers syndrome
• (M) 163.3 Cerebral Infarction due to thrombosis
  of cerebral arteries
• (3) G46.3 Brain stem stroke syndrome (includes
  Webers Syndrome)

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Classification based on MRDx

• MCC 1 Diseases and Disorders of the Nervous
  System
• CMG 13 Specific cerebrovascular disorders
• Medical includes SAH, ICH, SDH, stroke NOS
• With surgery, i.e. Drainage of SDH CMG 1
  Craniotomy procedures