A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity. Per ICD-10 official guidelines for reporting and coding “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved.”
Documentation & Coding Tips
Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection
Seizure Classes:
- Focal/partial (localization-related) seizures: start in one part of the brain and spread to others. The person may notice minor symptoms and feel that something is about to happen. As it spreads across the brain, more symptoms occur.
- Generalized seizures: surges of abnormal nerve discharges throughout the cortex of the brain, at the same time. Includes terms such as absence (petit mal), myoclonic, tonic, atonic, clonic, and tonic-clonic (grand mal)
Specificity:
- Intractability:
- Not Intractable
- Intractable: equivalent terms include pharmacologically resistant, treatment resistant, refractory (medically) and poorly controlled
- Status epilepticus: with or without
- Causative factors: alcohol, drugs, hormonal changes, sleep deprivation, stress, idiopathic, etc.
Documentation: Medications, treatment & response
- Epilepsy is incurable but can be controlled or limited by medications, diet, devices, or surgical techniques
- historical seizure/convulsion only, not ongoing