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

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 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.

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) † 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 System  CMG 13 Specific cerebrovascular disorders Medical includes SAH, ICH, SDH, stroke NOS With surgery, i.e. Drainage of SDH CMG 1 Craniotomy procedures