Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
150022 Triggering evidence: Documentation of increased intracranial pressure (ICP) OR mass effect of brain OR midline shift of brain : • Compression of brain • Raised intracranial pressure AND (+/-) clinical, medication OR treatment evidence of increased intracranial pressure: • Diuretic • Phenobarbital • Craniectomy • Drainage of cerebrospinal fluid • Ventriculostomy Satisfying evidence: Documentation of the etiology of increased intracranial pressure (ICP) OR mass effect of brain OR midline shift of the brain: • Cerebral edema • Brain stem herniation • Encephalopathy • Head trauma • Hydrocephalus • Intracranial mass |
✔ | ✔ | Documentation of increased ICP or mass effect or midline shift of brain (+/- clinical, medication, or treatment evidence of increased ICP) without documentation of the etiology of increased ICP or mass effect or midline shift of brain | INCREASED INTRACRANIAL PRESSURE Please document the etiology of increased ICP or mass effect or midline shift of brain. |
✔ | ✔ | ✔ | |
51000842R Triggering evidence: Radiology evidence of midline shift or mass effect of the brain AND Evidence of treatment of elevated intracranial pressure: • Diuretics • Decadron • Phenobarbital • Craniectomy • Drainage of cerebrospinal fluid • Ventriculostomy Satisfying evidence: Documentation of mass effect or midline shift of the brain: • Midline shift of the brain • Mass effect due to brain mass |
✔ | ✔ | Radiologic evidence of midline shift or mass effect and treatment evidence of elevated ICP without documentation of midline shift or mass effect | UNSPECIFIED CLINICAL CONDITION-L The radiology report contains evidence of a brain condition and there is evidence of treatment of elevated intracranial pressure. Please document any associated diagnosis. |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
40901 Triggering evidence: Documentation of cerebral palsy Satisfying evidence: Documentation of the type of cerebral palsy: • Cerebral palsy • Congenital flaccid paralysis • Congenital paraplegia |
✔ | ✔ | Documentation of cerebral palsy without documentation of the type of cerebral palsy | CEREBRAL PALSY Please document the type of cerebral palsy. |
✔ | ✔ | ✔ |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
51002802 Triggering evidence: Documentation of a cranial OR nasal procedure: • Including but not limited to: • Transsphenoidal approach • Excision of pituitary • Carniofacial procedures • Nasal septoplasty AND clinical evidence of cerebrospinal fluid leak: • Metallic taste • Loss of sense of smell • Nasal discharge Satisfying evidence: Documentation of a cerebrospinal fluid leak |
✔ | ✔ | Documentation of a cranial or nasal procedure and clinical evidence of a cerebrospinal fluid leak without documentation of a CSF leak | UNSPECIFIED CLINICAL CONDITION - K There is documentation of a cranial or nasal procedure and clinical evidence of nasal drainage, ansomia or metallic taste. Please document any assoicated daignosis. |
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Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
150001 Triggering evidence: Documentation of stroke : • Cerebrovascular infarction • Hemorrhagic cerebral infarction • Paralytic stroke AND Documentation of a paresis OR plegia : • Hemiplegia • Monoplegia • Hemiparesis • Left/right sided weakness (+/-) Clinical evidence of stroke: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of the affected side as dominant OR nondominant: • Hemiplegia of dominant side • Hemiplegia of nondominant side • Monoplegia of dominant side • Monolplegia of non dominant side |
✔ | ✔ | Documentation of a stroke and a paresis or plegia (+/- clinical evidence of stroke) without documentation of the affected side as dominant or nondominant | PLEGIA/PARESIS Please document the dominance of the side affected by the -plegia or -paresis. |
✔ | |||
150002 Triggering evidence: Documentation of stroke: • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke AND MIN,2 documentation of 'unresponsiveness' : • Unresponsiveness • Unconscious • Disturbance of consciousness (+/-) Clinical evidence of stroke: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of the level of responsiveness: • Including but not limited to: • Delirium • Coma • Dementia • Stupor • Obtundation |
✔ | ✔ | Documentation of stroke and unresponsiveness (+/- clinical evidence of stroke) without documentation of the level of unresponsiveness (stupor, coma, or locked-in syndrome) | LEVEL OF RESPONSIVENESS Please document the level associated with responsiveness, if known. |
✔ | ✔ | ✔ | |
150004 Triggering evidence: Documentation of stroke OR cerebral ischemia : • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke • Ischemic stroke (+/-) Evidence of the type of stroke: • Embolus • Hemorrhage • Infarct • Ischemia • Stenosis • Thrombus Satisfying evidence: Documentation of the type of stroke: • Thrombotic stroke • Ischemic stroke • Occlusive stroke • Embolic stroke • Hemorrhagic stroke |
✔ | ✔ | Documentation of stroke (+/- evidence of the type of stroke) without documentation of the type of stroke | STROKE TYPE Please document the type of cerebral ischemia or infarction. |
✔ | ✔ | ✔ | ✔ |
150005 Triggering evidence: Documentation of stroke: • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke (+/-) clinical evidence of stroke: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of residual hemiparesis: • Hemiplegia • Hemiparesis • Monoparesis • Monopleagia • Paralytic syndrome • Paresis of the limb |
✔ | ✔ | Documentation of stroke (+/- clinical evidence of stroke) without documentation of the presence or absence of residual hemiparesis | STROKE: RESIDUAL HEMIPARESIS There is documentation of stroke. Please document whether the patient has any associated physical manifestations. |
✔ | |||
150007 Triggering evidence: Documentation of brain hemorrhage (+/-) clinical evidence of brain hemorrhage: • Including but not limited to: • Headache • Loss of consciousness • Nausea • Vertigo • Seizure Satisfying evidence: Documentation of the type of brain hemorrhage: • Including but not limited to: • Intracerebral hemorrhage • Intraventricular hemorrhage • Epidural hemorrhage • Subdural hemorrhage • Subarachnoid hemorrhage |
✔ | ✔ | Documentation of brain hemorrhage (+/- clinical evidence of brain hemorrhage) without documentation of the type of brain hemorrhage | BRAIN HEMORRHAGE Please document the type of brain hemorrhage. |
✔ | ✔ | ✔ | |
150013 Triggering evidence: Documentation of stroke (+/-) clinical evidence of stroke : • Including but not limited to: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of sequela of stroke : • Including but not limited to: • Aphasia • Apraxia • Ataxia • Dysarthria • Hemiparesis • Weakness |
✔ | ✔ | Documentation of stroke (+/- clinical evidence of stroke) without documentation of sequela of stroke | STROKE CONDITIONS There is documentation of stroke. Please document any residual conditions, if applicable. |
✔ | ✔ | ||
150014 Triggering evidence: Documentation of stroke OR cerebral infarction (+/-) clinical evidence of stroke: • Including but not limited to: • Aphasia • Apraxia • Dysarthria • Spasticity • Muscle weakness Satisfying evidence: Documentation of the site of the stroke OR cerebral infarction: • Anterior cerebral circulation hemorrhagic infarction • Brainstem stroke syndrome • Cerebellar stroke syndrome • Posterior cerebral circulation hemorrhagic infarction • Thrombosis od intracrantial venous sinus |
✔ | ✔ | Documentation of stroke (+/- clinical evidence of stroke) without documentation of the site of stroke | STROKE SITE Please document the site of cerebral ischemia or infarction, if known. |
✔ | |||
150026A Triggering evidence: Documentation of stroke: • Cerebrovascular infarction • Hemoragic cerebral infarction • Paralytic stroke AND evidence of behavioral disturbances: • Altered mental status • Anxiety • Delirium • Depressive disorder • Hallucination • Stupor Satisfying evidence: Documentation of vascular dementia OR documentation of the etiology of the behavioral disturbances: • Including but not limited to: • Altered mental status • Anxiety • Delirium • Depressive disorder • Hallucination • Stupor • Any physician documented cause of behavioral disturbances • Idiopathic • Multifactorial |
✔ | ✔ | Documentation of stroke or a history of stroke and documentation of a behavioral disturbance without documentation of vascular dementia or the etiology of the behavioral disturbance (age: > 18 years) | STROKE - BEHAVIORAL DISTURBANCE There is documentation of stroke and behavioral disturbances. Please clarify whether these are causally related. |
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150027* Triggering evidence: Documentation of stroke : • Cerebrovascular infarction • Hemorrhagic cerebral infarction • Paralytic stroke AND documentation of paresis OR plegia : • Hemiparesis • Hemiplegia • Monoparesis • Monoplegia • Muscle weakness • Paralytic syndrome AND documentation of decubitus ulcer |
✔ | Notification: Documentation of stroke, paresis or plegia, and decubitus ulcer | ||||||
Cerebrovascular-001 Triggering evidence: Documentation of acute stroke Satisfying evidence: Documentation the presence or absence of coma AND documentation of NIHSS score |
✔ | ✔ | Documentation of acute stroke without documentation of NIHSS score and presence or absence of coma | ACUTE STROKE There is documentation of acute stroke. Please document NIHSS score and presence or absence of coma, if known. |
✔ |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
OtherNervous-002 Triggering evidence: Evidence of Glasgow coma score < 9 (+/-) clinical evidence of coma : • Absent corneal reflexes • Decerebrate posture • Decorticate posture • Fixed dilation of pupil • No pupillary reaction to light • Persistent vegetative state • Unconscious/ Unresponsive AND NO documentation of drug-induced coma Satisfying evidence: Documentation of coma |
✔ | ✔ | Evidence of Glasgow coma score < 9 (+/- clinical evidence of coma) without documentation of coma | LOW GCS There is evidence of Glasgow coma score < 9. Please document any associated diagnosis. |
✔ | ✔ |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
150011 Triggering evidence: Documentation of closed head injury OR traumatic brain injury: • Closed head injury (CHI) • Traumatic brain injury (TBI) • Concussion • Contusion • Diffuse axonal injury • Intracranial hematoma (+/-) Clinical evidence of concussion: • Nausea and vomiting • Altered mental status • Dizziness • Persistent headache Satisfying evidence: Documentation of concussion: • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion |
✔ | ✔ | Documentation of closed head injury or traumatic brain injury (+/- clinical evidence of concussion) without documentation of concussion | HEAD INJURY There is documentation of closed head injury. Please document any associated diagnosis. |
✔ | ✔ | ✔ | |
150018 Triggering evidence: Documentation of loss of consciousness (LOC) Satisfying evidence: Documentation of the duration of loss of consciousness (LOC) |
✔ | ✔ | Documentation of loss of consciousness without documentation of the duration of loss of consciousness | LOSS OF CONSCIOUSNESS Please document the duration of LOC, if known. |
✔ | ✔ | ✔ | |
150019 Triggering evidence: Documentation of concussion : • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion (+/-) evidence of LOC unspecified duration (+/-) evidence of LOC with >=30 min time element Satisfying evidence: Documentation of initial, subsequent OR sequela visit |
✔ | ✔ | Documentation of concussion (+/- evidence of duration of loss of consciousness) without documentation of visit type (initial, subsequent, or sequela) | CONCUSSION There is documentation of concussion. Please specify visit type. |
✔ | ✔ | ✔ | |
150020 Triggering evidence: Documentation of concussion : • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion AND documentation of loss of consciousness (LOC) Satisfying evidence: Documentation of the duration of loss of consciousness (LOC): • Loss of consciousness (LOC) |
✔ | ✔ | Documentation of concussion and loss of consciousness without documentation of the duration of loss of consciousness | CONCUSSION WITH LOC Please document the duration of LOC associated with the concussion, if known. |
✔ | ✔ | ||
OtherNervous-001 Triggering evidence: Documentation of concussion: • Brain injury with concussion • Brain stem laceration with concussion • Cerebellar contusion with concussion • Open head injury with concussion Satisfying evidence: Documentation of the presence or absence of loss of consciousness (LOC) |
✔ | ✔ | Documentation of concussion without documentation of the presence or absence of loss of consciousness | CONCUSSION - B There is documentation of concussion. Please document any associated diagnosis. |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
12012P Triggering evidence: Documentation of hypoxic ischemic encephalopathy Satisfying evidence: Documentation of the severity of the hypoxic ischemic encephalopathy: • Mild • Moderate • Severe |
✔ | ✔ | Pediatric: Documentation of hypoxic ischemic encephalopathy without documentation of the severity of encephalopathy (age: < 1 year) | HYPOXIC ISCHEMIC ENCEPHALOPATHY Please document the severity of hypoxic ischemic encephalopathy. |
✔ | ✔ | ✔ | |
57001A Triggering evidence: Documentation of encephalopathy (+/-) Clinical evidence of encephalopathy: • Altered mental status • Asterixis • Hallucinations • Hypercapnia • Seizure • Lethargy (+/-) Lab evidence of encephalopathy: • Magnesium <= 1 • Calcium <=6 or >=13 • Sodium <=130 or >145 • Thiamine <2.5 • Phosphorus <2 • Ammonia >100 umol/L • Glucose <50 mg/dL • GFR <15 mL/min • pCO2 arterial >45 mmHg • pCO2 venous >45 mmHg • pO2 arterial <60 mmHg • Vitamin B12 <200 pg/mL • O2 sat <90% Satisfying evidence: Documentation of the etiology OR type of encephalopathy: • Including but not limited to: • Hypertensive encephalopathy • Infectious encephalopathy • Metabolic encephalopathy • Toxic encephalopathy • Hepatic encephalopathy • Any provider linked cause of encephalopathy • Idopathic encephalopathy • Multifactorial encephalopathy |
✔ | ✔ | Documentation of encephalopathy (+/- clinical or lab evidence of encephalopathy) without documentation of the type or etiology of encephalopathy (age: > 18 years) | ENCEPHALOPATHY - TYPE Please document the type or etiology of encephalopathy. |
✔ | ✔ | ✔ | ✔ |
57002 Triggering evidence: Documentation of encephalopathy AND Clinical evidence of coma : • Absent corneal reflexes • Decerebrate posture • Decorticate posture • Fixed dilation of pupil • No pupillary reaction to light • Persistent vegetative state • Unconscious/ Unresponsive OR GCS > 9 Satisfying evidence: Documentation of coma |
✔ | ✔ | Documentation of encephalopathy and clinical evidence of coma without documentation of coma | ENCEPHALOPATHY There is documentation of encephalopathy and clinical evidence of decreased responsiveness. Please document any associated diagnosis. |
✔ | ✔ | ✔ | ✔ |
57004 Triggering evidence: Documentation of altered mental status OR confusion: • Acute confusion • Clouded consciousness • Confused • AMS Satisfying evidence: Documentation of the presence OR absence of encephalopathy: • Traumatic encephalopathy • Hashimoto’s encephalopathy • Ischemic encephalopathy • Hypertensive encephalopathy • Infectious encephalopathy • Metabolic encephalopathy • Wernicke Encephalopathy • Hepatic encephalopathy |
✔ | ✔ | Documentation of altered mental status or confusion without documentation of the presence or absence of encephalopathy | ALTERED MENTAL STATUS - D Altered mental status or confusion have been documented. Please document any associated diagnosis. |
✔ | ✔ | ✔ | ✔ |
57005 Triggering evidence: Documentation of AMS AND MIN,2 Clinical evidence of encephalopathy OR metabolic encephalopathy: • Including but not limited to: • Ataxia • Hyponatremia • Agitation • Decreased level of consciousness • AKI • Respiratory failure • Electrolyte imbalance OR Lab evidence of encephalopathy: • Magnesium <= 1 • Calcium <=6 or >=13 • Sodium <=130 or >145 • Thiamine <2.5 • Phosphorus <2 • Ammonia >100 umol/L • Glucose <50 mg/dL • GFR <15 mL/min • pCO2 arterial >45 mmHg • pCO2 venous >45 mmHg • pO2 arterial <60 mmHg • Vitamin B12 <200 pg/mL • O2 sat <90% OR Chemical evidence of encephalopathy: • Including but not limited to: • Antihymocyte immunoglobulin • Organic chemical solvents • Formalin • Formaldehyde • Tetrachloroethylene Satisfying evidence: Documentation of metabolic encephalopathy: • Metabolic encephalopathy • Toxic encephalopathy • Sepsis-associated encephalopathy • Hypertensice encephalopathy • Hepatic encephalopathy • Alcoholic encephalopathy |
✔ | ✔ | Documentation of altered mental status and clinical evidence of metabolic encephalopathy or clinical, lab, or medication evidence of encephalopathy without documentation of metabolic encephalopathy | ALTERED MENTAL STATUS - C There is evidence of a neurological disorder. Please document any associated diagnosis. |
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Encephalopathy-001 Triggering evidence: Documentation of encephalopathy Satisfying evidence: Documentation of the type OR etiology of encephalopathy: • Including but not limited to: • Hypertensive encephalopathy • Infectious encephalopathy • Metabolic encephalopathy • Toxic encephalopathy • Hepatic encephalopathy • Any provider linked cause of encephalopathy • Idopathic encephalopathy • Multifactorial encephalopathy AND Clinical evidence of encephalopathy: • Altered mental status • Asterixis • Hallucinations • Hypercapnia • Seizure • Lethargy OR Lab evidence of encephalopathy: • Magnesium <= 1 • Calcium <=6 or >=13 • Sodium <=130 or >145 • Thiamine <2.5 • Phosphorus <2 • Ammonia >100 umol/L • Glucose <50 mg/dL • GFR <15 mL/min • pCO2 arterial >45 mmHg • pCO2 venous >45 mmHg • pO2 arterial <60 mmHg • Vitamin B12 <200 pg/mL • O2 sat <90% |
✔ | ✔ | Documentation of encephalopathy without clinical or lab evidence of encephalopathy and documentation of type or etiology of encephalopathy | ENCEPHALOPATHY TYPE AND EVIDENCE Please specify the type or etiology of encephalpathy and include clinical indicators supporting the diagnosis. |
✔ | ✔ | ✔ | ✔ |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
150008 Triggering evidence: Documentation of hydrocephalus: • Communicating hydrocephalus • Hydrocephalus • Normal pressure hydrocephalus • Obstructive hydrocephalus Satisfying evidence: Documentation of the type of hydrocephalus: • Communicating hydrocephalus • Normal pressure hydrocephalus • Obstructive hydrocephalus |
✔ | ✔ | Documentation of hydrocephalus without documentation of the type of hydrocephalus | HYDROCEPHALUS Please specify the type of hydrocephalus, if known. |
✔ | ✔ | ||
150009 Triggering evidence: Documentation of VP (ventricular peritoneal) shunt: • Including but not limited to: • Ventriculoperitoneal shunt • Ventriculoperitoneal shunt malfunction • Ventriculoperitoneal shunt infection Satisfying evidence: Documentation of hydrocephalus: • Communicating hydrocephalus • Hydrocephalus • Normal pressure hydrocephalus • Obstructive hydrocephalus |
✔ | ✔ | Documentation of ventriculoperitoneal shunt without documentation of hydrocephalus | VP SHUNT There is documentation of VP (ventricular peritoneal) shunt. Please document the underlying condition. |
✔ | ✔ | ||
150017* Triggering evidence: Documentation of VP (ventriculoperitoneal) shunt: • Ventriculoperitoneal shunt • Ventriculoperitoneal shunt peritonitis • Ventriculoperitoneal shunt malfunction • Ventriculoperitoneal shunt infection |
✔ | Notification: Documentation of ventriculoperitoneal shunt |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
Metastatic-001 Triggering evidence: Documentation of a brain tumor AND No documentation of glioma AND No documentation of primary malignant neoplasm of brain AND No documentation of benign brain tumor Satisfying evidence: Documentation of the presence or absence of brain metastasis |
✔ | ✔ | Documentation of brain tumor without documentation of the presence or absence of metastatic brain disease | BRAIN TUMOR There is documentation of a brain tumor. Please document the status of metastatic brain disease, if known. |
✔ |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
12011 Triggering evidence: Documentation of abnormal gait: • Abnormal gait • Ataxic gait • Unsteady gait Satisfying evidence: Documentation of the type of abnormal gait: • Limping gait • Staggering gait • Spastic gait • Stumbling gait • Paraplegic gait |
✔ | ✔ | Documentation of abnormal gait without documentation of the type of abnormal gait | ABNORMAL GAIT Please document the type of gait abnormality. |
✔ | |||
150006 Triggering evidence: Documentation of ataxia Satisfying evidence: Documentation of the type of ataxia: • Including but not limited to: • Cerebellar ataxia • Friedreich's ataxia • Idiopathic ataxia • Episodic ataxia • Ataxia-telangiectasia syndrome OR Documentation of the etiology of ataxia: • Head injury • Stroke • Cerebral palsy • Encephalitis/meningitis • Multiple sclerosis • Any provider linked cause of ataxia |
✔ | ✔ | Documentation of ataxia without documentation of the type or etiology of ataxia | ATAXIA Please document the type or etiology of ataxia. |
✔ | ✔ | ✔ | |
150010 Triggering evidence: Documentation of aphasia: • Anomic aphasia • Broca's dysphasia • Expressive aphasia • Global aphasia • Mixed dysphasia • Receptive dysphasia Satisfying evidence: Documentation of the type of aphasia: • Anomic aphasia • Expressive aphasia • Global aphasia • Mixed dysphasia • Receptive dysphasia |
✔ | ✔ | Documentation of aphasia without documentation of the type of aphasia | APHASIA Please document the type of aphasia. |
✔ | |||
150012 Triggering evidence: MIN 2, Documentation of seizure: • Seizure disorder • Partial seizure • Epilepsy • Simple seizure • Partial seizure • Focal seizure • Satisfying evidence: Documentation of the type of seizure: • Absence seizure • Atypical seizure • Clonic seizure • Myoclonic seizure • Tonic seizure • Atonic seizure • OR documentation of unknown type of seizure |
✔ | ✔ | Documentation of seizure without documentation of type of seizure | SEIZURE Please document the type of seizure. |
✔ | ✔ | ✔ | |
150016* Triggering evidence: Documentation of weakness, hemiparesis, hemiplegia, monoparesis, OR monoplegia |
✔ | Notification: Documentation of weakness, hemiparesis, or hemiplegia, or monoparesis, or monoplegia | ||||||
150021 Triggering evidence: Documentation of dysarthria OR anarthria: • Flaccid dysarthria • Spastic dysarthria • Ataxic dysarthria • Hypokinetic dysarthria • Hyperkinetic dysarthria • Mixed type dysarthria Satisfying evidence: Documentation of the etiology of dysarthria OR anarthria: • Traumatic/non-traumatic brain injury • Cerebral palsy • Multiple sclerosis • Parkinson's disease • Huntington's disease • Mass lesion of the brain |
✔ | ✔ | Documentation of dysarthria or anarthria without documentation of the etiology of dysarthria or anarthria | DYSARTHRIA/ANARTHRIA Please document the etiology of dysarthria or anarthria, if known. |
✔ | |||
150023 Triggering evidence: Documentation of EMG OR nerve conduction study Satisfying evidence: Documentation of limb AND laterality : • Including but not limited to: • Entire limb • Upper limb • Lower limb • Entire forearm |
✔ | ✔ | Documentation of EMG or nerve conduction study without documentation of limb with laterality | EMG Please document the anatomic site of the EMG/nerve conduction study. |
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150024 Triggering evidence: Documentation of weakness: • Asthenia • Muscle weakness Satisfying evidence: Documentation of the laterality of weakness: • Unilateral • Unspecified laterality |
✔ | ✔ | Documentation of weakness without documentation of the laterality of weakness | WEAKNESS Please document the laterality of weakness. |
✔ | ✔ | ||
43006 Triggering evidence: MIN,2 Documentation of diabetes : • Including but not limited to: • Diabetes mellitus • Gestational diabetes • Brittle diabetes • Diabetic foot ulcer AND documentation of a neuropathic agents: • Anticonvulsants Satisfying evidence: Documentation of diabetic peripheral neuropathy |
✔ | ✔ | Documentation of diabetes and a neuropathic agent without documentation of diabetic peripheral neuropathy | DIABETES - NEUROPATHIC AGENTS There is documentation of diabetes and a neuropathic agent. Please document any associated diagnosis. |
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OtherNervous-003 Triggering evidence: MIN,2 Documentation of seizure : • Generalized seizure • Partial seizure • Familial neonatal seizure • Status epilepticus • Familial febrile convulsions (+/-) Evidence of seizure: • Including but not limited to: • Temperature >104.4 F or 40.22 C • Traumatic brain injury • Acohol or Drug abuse or withdrawal • TIA or CVA • Family history of seizures Satisfying evidence: Documentation of the type of seizure : • Including but not limited to: • Tonic seizure • Atonic seizure • Myoclonic seizure • Clonic seizure • Grand mal OR documentation of unknown type of seizure |
✔ | ✔ | Documentation of seizure (+/- clinical evidence or family history of seizure) without documentation of the type of seizure | SEIZURE - B Please document the type of seizure. |
✔ | ✔ | ✔ |
Code | Product | Description | Physician Message | Risk Classification | ||||
---|---|---|---|---|---|---|---|---|
E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
41001 Triggering evidence: Documentation of spina bifida: • Spina bifida • Meningocele • Myelomeningocele • Closed neural tube defect Satisfying evidence: Documentation of the affected spinal segment: • Including but not limited to: • Cerebral meningocele • Spina bifida of lumbar region • Spina bifida of thoracic region • Spina bifida of sacral region • Spina bifida of cervical region |
✔ | ✔ | Documentation of spina bifida without documentation of the affected spinal segment | SPINA BIFIDA Please document the spinal level of spina bifida. |
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Code | Product | Description | Physician Message | Risk Classification | ||||
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E11 | CDI2 | CC | MCC | HCC | MS-DRG | |||
150025 Triggering evidence: MIN,2 documentation of transient ischemic attack : • Transient ischemic attack • Carotid territory transient ischemic attack • Recurrent transient ischemic attack (+/-) documentation of a history of stroke (+/-) clinical evidence of the etiology of transient ischemic attack : • Atrial fibrillation • Arteriosclerosis • Hypercholesterolemia • Hypertension Satisfying evidence: Documentation of the etiology of transient ischemic attack: • Including but not limited to: • Hypertension • Arrythmia • Arteriosclerosis • Hypercholesterolemia • Any physician documented cause of transient ischemic attack |
✔ | ✔ | Documentation of transient ischemic attack (+/- history of stroke or clinical evidence of the etiology of TIA) without documentation of the etiology of transient ischemic attack | TRANSIENT ISCHEMIC ATTACK Please document the etiology of TIA, if known. |
✔ |