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March 28, 2011

Coding for Brain Aneurysms
For The Record
Vol. 23 No. 6 P. 27

A brain aneurysm is a bulging or ballooning in a weakened area in the wall of an artery that supplies blood to the brain. Also called a cerebral or intracranial aneurysm, it most often occurs in arteries at the base of the brain and looks like a berry hanging on a stem.

Brain aneurysm is assigned to ICD-9-CM code 437.3, Cerebral aneurysm, nonruptured. Code 437.3 also includes an aneurysm of the intracranial portion of the internal carotid artery. If the carotid artery aneurysm was of the external, common, or extracranial portion of the internal carotid artery, code 442.81, Aneurysm of artery of neck, should be assigned. A congenital brain aneurysm is classified to code 747.81, Anomalies of cerebrovascular system.

Most brain aneurysms don’t cause problems or symptoms. However, some may leak or even rupture, which causes bleeding in the brain (hemorrhagic stroke). A ruptured brain aneurysm is classified to code 430, Subarachnoid hemorrhage. Code 430 also includes a ruptured berry aneurysm and ruptured congenital brain aneurysm. Subarachnoid hemorrhage is bleeding in the space between the brain and the thin tissues covering the brain. A ruptured brain hemorrhage can be life threatening and requires immediate treatment.

As stated above, most nonruptured brain aneurysms do not cause symptoms, especially when the aneurysm is small. However, a large brain aneurysm may cause pain above and behind an eye; a dilated pupil; change in vision such as blurred vision, double vision, or peripheral vision deficits; drooping eyelid; perceptual problems or loss of balance and coordination; numbness, weakness, or paralysis of one side of the face; speech complications; decreased concentration; short-term memory difficulty; or a sudden change in behavior.

A ruptured aneurysm has many of the same symptoms as a nonruptured brain aneurysm. Symptoms specific to ruptured brain aneurysms are a sudden and extremely severe headache, which the patient may describe it as the “worst headache ever”; nausea and vomiting; a stiff neck or neck pain; sensitivity to light; a seizure; and loss of consciousness or fainting.

When a patient is suspected of having an aneurysm, a physician may order a CT scan to determine whether there is bleeding in the brain and the location; CT angiography or tomographic angiography, which involves injecting dye into the body to make it easier to observe blood flow to determine the exact location, size, and shape of the aneurysm; a lumbar puncture or spinal tap to detect blood cells in the cerebrospinal fluid; an MRI scan of the brain; MRI angiography; and/or a cerebral angiogram.

Physicians may choose not to treat a nonruptured brain aneurysm, especially if it is small or not causing any symptoms. However, it may be appropriate to treat some nonruptured brain aneurysms to prevent a future rupture.

Two common surgical procedures for addressing ruptured or nonruptured brain aneurysms are clipping and endovascular repair. Surgical clipping of the brain aneurysm involves applying a clip to the aneurysm so blood no longer flows to it. This is an open surgical approach and carries a high surgical risk. Clipping of an aneurysm is assigned to code 39.51.

Endovascular embolization involves inserting a catheter into an artery, usually one in the groin, and threads a device into the aneurysm to disrupt the blood flow and cause the blood to clot. This procedure seals off the aneurysm from the artery.

The most common type of device used to treat brain aneurysms are coils. Currently, there are two types of coils used: bare platinum coils (BPCs) and bioactive coils. Endovascular embolization of a brain aneurysm using BPCs is classified to code 39.75 and includes bare metal coils. Endovascular embolization of a brain aneurysm using bioactive coils is assigned to code 39.76 and includes biodegradable inner luminal polymer coils and coils containing polyglycolic acid.

Endovascular embolization of a brain aneurysm using a device other than coils is assigned to code 39.72, Endovascular embolization or occlusion of head and neck vessels. Since the creation of codes 39.75 and 39.76 in 2009, coil embolization of a brain aneurysm is no longer classified to code 39.72. It may be necessary to query the physician for clarification if the documentation does not provide information on the type of coil inserted.

Coding and sequencing for brain aneurysm are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.


Coding for Endovascular Embolization in ICD-10-PCS
To assign the most appropriate procedure code in ICD-10-PCS, it is extremely important to identify the correct root operation. The root operation, which is the third character of the ICD-10-PCS code, defines the objective of the procedure. According to the ICD-10-PCS Coding Guidelines, “In order to determine the appropriate root operation, the full definition of the root operation as contained in the PCS Tables must be applied.”

In addition, there is a specific guideline regarding embolization procedures. Guideline B3.12 states, “If the objective of an embolization procedure is to completely close a vessel, the root operation Occlusion is coded. If the objective of an embolization procedure is to narrow the lumen of a vessel, the root operation Restriction is coded. … Embolization of a cerebral aneurysm is coded to the root operation Restriction, because the objective of the procedure is not to close off the vessel entirely, but to narrow the lumen of the vessel at the site of the aneurysm where it is abnormally wide.”

Therefore, the code assignment for coil embolization of an intracranial artery is 03VG3DZ. The following explains the meaning of each character:

• 0: Medical and Surgical (Section);

• 3: Upper Arteries (Body System);

• V: Restriction (Root Operation);

• G: Intracranial Artery (Body Part or Region);

• 3: Percutaneous (Approach);

• D: Intraluminal (Device); and

• Z: No Qualifier (Qualifier).

If bioactive coils were used, then the code assignment would be 03VG3BZ. The only difference in characters is the sixth character for device. It is interesting to note that clipping of a cerebral aneurysm through a craniotomy is classified to code 03VG0CZ. Most of the characters are the same as the endovascular embolization with the exception of the approach (fifth character), which is open, and device (sixth character), which is an extraluminal device.

— Audrey Howard