AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Quarter 1; Ask the Editor
Pseudoseizure with History of Seizures
A patient with a history of seizures was admitted to the hospital after being found passed out in the street, due to a syncopal episode and possible seizure activity. The provider listed the final diagnosis as “Likely pseudoseizures.” How should pseudoseizure in a patient with history of seizures be coded? ...
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Article Overview
This premium coding article discusses a documentation and coding clarification issue involving a patient with a seizure history and a suspected pseudoseizure diagnosis. It is relevant to hospital coders, CDI staff, and other coding professionals who need to understand when physician clarification is appropriate before final code assignment. The article presents general guidance on resolving ambiguous seizure-related documentation and selecting the appropriate diagnosis category once the record is clarified.
Why This Topic Matters
Ambiguous seizure documentation can affect diagnosis coding accuracy and the integrity of the medical record. This topic matters because it highlights when clarification is needed before assigning a final code in a case involving seizure history and a possible non-epileptic event.
What You Will Learn
- Why seizure-related documentation may require physician clarification
- How ambiguous neurologic event documentation affects code assignment
- What kinds of records may need review before final diagnosis coding in this scenario
- General considerations for handling a suspected pseudoseizure diagnosis in a patient with seizure history
Who Should Read This
- Hospital coders
- Clinical documentation integrity specialists
- Coding auditors
- Health information management professionals
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