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If you take care of patients with brain injuries, especially on the inpatient side, you’re bound to get a query asking if “brain compression” was present.

Brain compression?!

That’s not a term we physicians use.

When we think of processes leading towards the movement of structures in the brain, we describe those as “mass affect,” “midline shift,” or “herniation.”

Coding language and doctor language often don’t jive but this is frequently remedied by synonyms - that is terms that ARE used by providers but are understood to mean terms that do have specific ICD10 codes.

An example: There is no code for “chronic heart failure with reduced ejection fraction.” But there is a code for “chronic systolic heart failure.” Those are understood to be synonymous, therefore, chronic HFrEF will be coded as chronic systolic (congestive) heart failure I50.22.

There’s also no code for “Acute blood loss anemia.” This gets converted to the ICD10 code for “Acute Post-hemorrhagic anemia.”

Got it?

So, the problem?

“Mass affect,” “midline shift,” “space occupying lesion” and others are NOT synonyms for brain compression. They do not convey the same level of severity as brain compression from a coding perspective.

So, what is “brain compression?” It’s when pressure on the brain pushes the brain. This might be due to either internal (subarachnoid hemorrhage, large stroke, tumor, etc) or external (subdural hematoma) causes.

That definition makes sense…it’s just not the way we’re used to describing it.

Documentation Tips for Physicians & APP’s

• When you see the results of brain compression, document them together such as “Midline shift with brain compression” or “Narrowing of ventricles due to brain compression.” Don’t only document the midline shift, narrowing of the ventricles, etc.

• You can have brain compression with or without herniation. So, if both are present, document them both including the specific location of the herniation.

• Specify if it’s known to be traumatic or not (this is vital to the coding, of which I won’t bore you with)

• Cerebral edema is different from brain compression. Document both when present. Also, cerebral edema is not inherent to strokes, tumors or trauma so document it if present (along with your management).

• These cannot be captured by radiology reports. They must be mentioned in your note.

Coding professionals know there is MUCH confusion about this topic, but I wanted to simplify it for providers. I wasted hours confusing myself with outdated sources only to realize the S06.A codes (Traumatic brain compression and herniation) were relatively new additions in October of 2021. Don’t make my same mistake. Check the date of your sources. Those codes greatly simplify things.

I’m doing something different… I’m turning on comments for the web version of this email! Click the link below and let me know your thoughts or questions!

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Cut note-writing time by >50%

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