Coding corner: Improve medical record documentation for seizures and epilepsy

According to the Centers for Disease Control and Prevention, epilepsy affects about 2 million adults in the U.S. Epilepsy is sometimes called a seizure disorder, which is a disorder of the brain. A seizure is a short change in normal brain activity and is the main sign of epilepsy, but it could also occur due to other medical problems.

When a person has had two or more seizures, they’re considered to have epilepsy. Symptoms vary according to the part of the brain that’s affected. There can be multiple causes leading to a seizure.

Here are some examples of conditions associated with seizures and epilepsy:

• Developmental problems, such as cerebral palsy
• Head injuries
• Poisoning

Physician documentation must specify the reason for the seizure or convulsion, if known, such as seizure disorder, traumatic brain injury, genetic disorders or epilepsy. If the cause is unknown or documentation is lacking, only the symptoms can be coded, which could result in failure to capture the condition in the patient if present.

For example, if a provider diagnoses a patient with a seizure disorder, the ICD-9-CM code is 780.39. But if the patient has epilepsy, the provider must state epilepsy, which codes to ICD-9-CM 345.90. Documenting the specific condition is key to increasing the accuracy of coding.

Convulsions and seizures occur in certain types of epilepsy, but they can also be symptoms of many other diseases, such as cerebrovascular accident, brain tumor, alcoholism and electrolyte imbalance. Therefore, the code for epilepsy should not be assigned unless the physician specifically states epilepsy as a condition in the diagnostic statement.

The different types of seizures are grand mal, myoclonic, atonic, tonic, clonic and absence. Accurate documentation of the seizure type is important in order to assign the correct ICD-9-CM or ICD-10-CM codes.

Epilepsy and recurrent seizures require a fifth digit code for ICD 9 represented by "X" in the table to describe if intractable epilepsy is present or not. Intractable epilepsy means that it’s difficult to control using anticonvulsant medications such as Phenytoin or Phenobarbital.

By comparison, ICD-10 has a greater number of codes to accommodate higher specificity in capturing diagnoses. This will be important to remember when ICD-10 codes go into effect beginning Oct. 1, 2015.

If you have questions or need more information, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.