Cerebral Edema & Brain Compression

Cerebral Edema Definition: Swelling of the brain. Can result from a variety of derangements that can stem from trauma, hypoxia, infection, CVA, intracerebral hemorrhage, metabolic derangements, hepatitis, Reye syndrome, carbon monoxide poisoning, lead poisoning, high altitude, acute hypertension, or tumors. 

Brain Compression Definition: Increased pressure pushing on the brain causing displacement that can lead to herniation.

Brain Herniation Definition: Occurs when increased intracranial pressure causes abnormal protrusion of brain tissue through openings in rigid intracranial barriers (tentorial notch, falx cerebri, foramen magnum). Classified based on the structure through which tissue is herniated. Types include: transtentorial (uncal), subfalcine, central, upward transtentorial or tonsillar. Common etiologies include, but are not limited to, traumatic epidural/subdural hematoma, malignant infarction, tumors, infections, hydrocephalus, diffuse subarachnoid hemorrhage, pneumocephalus (traumatic or postoperative), CSF over drainage, metabolic-hepatic encephalopathy, contusion, or intracerebral hemorrhage. 

Diagnostic Criteria

• Brain CT and/or MRI will confirm the presence of cerebral edema, compression, and/or herniation. 
• Brain herniation signs/symptoms can be more pronounced depending on the degree of herniation.  
• Cerebral edema can be asymptomatic, only seen on imaging, or cause life-threatening complications, varying widely depending on the location/extent of the cerebral edema.  
• Signs and symptoms can include visual disturbances, seizures, sensory changes, diplopia, headaches, N/V, lethargy, AMS/confusion, respiratory irregularities, fixed unequal pupils, ataxia to abnormal posturing, coma and even death. 

Coding Considerations

Review pertinent Coding Clinics such as:

• AHA Coding Clinic Fourth Quarter 2021, p. 29 ICD-10-CM New/Revised Codes: Traumatic Brain Compression and Herniation 
• AHA Coding Clinic Second Quarter 2020, p. 31 Traumatic Brain Injury with Herniation 
• AHA Coding Clinic Fourth Quarter 2022, p. 42 New/Revised ICD-10-CM Codes: Intracranial Injury with Unknown Loss of Consciousness 
• AHA Coding Clinic Third Quarter 2022, p. 9 Lung and Brain Metastases, Intracerebral hemorrhage, and Vasogenic Cerebral Edema 
• AHA Coding Clinic Third Quarter 2022, p. 10 Vasogenic Cerebral Edema and Breast Cancer with Brain Metastases 

An Excludes1 note identifies cerebral edema due to birth injury (P11.0) and traumatic cerebral edema (S06.1-) cannot be coded with Cerebral edema (G93.6) 

Inclusion terms for Traumatic cerebral edema include diffuse traumatic cerebral edema and focal traumatic cerebral edema. 

ICD-10-CM identifies traumatic cerebral edema based on loss of consciousness, then duration. When the 7th character is identified as A, initial encounter, these codes are designated as MCC’s. Note: 7th characters D and S do not apply to codes in category S06 with 6th character 7-death due to brain injury prior to regaining consciousness, or 8-death due to other cause prior to regaining consciousness.  

An Excludes1 note identifies that traumatic compression of the brain (S06.A-) cannot be coded with Compression of the brain (G93.5)

Inclusion terms for Compression of the brain include Arnold-Chiari type 1 compression of brain, Compression of brain (stem), and Herniation of brain (stem). 

CD-10-CM identifies traumatic brain compression as with (S06A1-) or without herniation (S06.A0-). When the 6th character is identified as A, initial encounter, these codes are designated as MCC’s. Category S06.A codes have a Code First notation for the underlying traumatic brain injury, such as:

• Diffuse traumatic brain injury (S06.2-) 
• Focal traumatic brain injury (S06.3-) 
• Traumatic subdural hemorrhage (S06.5-) 
• Traumatic subarachnoid hemorrhage (S06.6-) 

Several category S06 codes as well as G96.6 and G96.5 map to HCCs and can affect Risk Adjustment scores. 

CDI Practice Considerations

• Review documentation (including CT/MRI findings) for the underlying etiology, first noting if the cause is due to trauma, then further noting the underlying root origin of the original insult causing of the cerebral edema, brain compression or herniation, querying when necessary. 
• Clinically validating the presence of Cerebral Edema and Brain Compression is common for mitigating denials as they are typically MCCs impacting MS-DRG assignment. Minor localized edema surrounding a lesion identified on CT or MRI can be an intrinsic finding associated with the underlying etiology. Ensure the cerebral edema is clinically significant or identified as generalized brain swelling and meet the definition of a secondary diagnosis per ICD-10-CM Official Coding Guidelines, querying when necessary. Note: It is inappropriate to report an incidental finding found on a radiology report when the finding is unrelated to the sign, symptom, or condition that caused the performance of the test. The provider would need to clarify that the finding was clinically significant and related to the visit for it to be coded. 
• Review for related comorbidities such as Coma, Brain Death, Sepsis, Acute Hypoxic Respiratory Failure, AKI, and other body system failures. 
• Terms that indicate brain compression that require a query to clarify, if clinically significant, include ventricular effacement, sulcal effacement; cisternal effacement, uncal deviation, shift of midline structures and mass effect. 
• Treatment for cerebral edema and brain compression/herniation will focus on preventing further injury and direct towards the underlying etiology, attempting to remediate.   
• Cerebral Edema, Brain Compression, and Brain Herniation are not considered integral to many nontraumatic brain diseases/disorders or traumatic brain injuries. Therefore, review the record closely for clinical indicator support and query when necessary. Capturing these diagnoses as comorbidities will accurately reflect the patient’s complexity and severity in the coded data and may impact MS-DRG assignment. 
• Examine nursing assessments closely when reviewing clinical indicator support, specifically noting Glasgow Coma Scale (GCS) scores, National Institute of Health Stroke Scale (NIHSS) scores and, if applicable, Intracranial Pressure (ICP) monitoring.  

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