Find comprehensive information on documenting a history of brain aneurysm for accurate clinical care and medical coding. This resource covers diagnosis codes, clinical documentation improvement CDI best practices, past pointing, subarachnoid hemorrhage SAH, risk factors, family history, previous rupture, diagnostic imaging reports, and treatment history for brain aneurysms. Learn how to properly document a patient's history of brain aneurysm to ensure optimal patient care and accurate reimbursement.
Also known as
Cerebral aneurysm, non-ruptured
History of a non-ruptured aneurysm in the brain.
Cerebrovascular diseases
Encompasses various cerebrovascular conditions, including aneurysms.
Other cerebrovascular diseases
Includes other specified cerebrovascular diseases like dissecting aneurysms.
Personal history of aneurysm
Indicates a past history of an aneurysm, not currently active.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the brain aneurysm ruptured?
Yes
Is there subarachnoid hemorrhage?
No
Is the aneurysm currently being treated?
When to use each related code
Description |
---|
Brain Aneurysm |
Subarachnoid Hemorrhage |
Intracranial Hemorrhage, NOS |
Coding I77.9 (unspecified aneurysm) when documentation specifies location. Requires more specific ICD-10 code for accurate reimbursement and quality reporting.
Failing to distinguish between ruptured (I60.-) and unruptured (I77.1) aneurysm impacts severity and subsequent care documentation requirements.
Lack of imaging or procedural reports confirming the aneurysm diagnosis leads to coding queries and potential denial of claims. Clear documentation is crucial.
Patient presents with a history of intracranial aneurysm. Initial diagnosis of brain aneurysm was confirmed on [Date] via [Diagnostic imaging modality, e.g., cerebral angiography, CT angiography, MRI]. Aneurysm location was documented as [Specific location, e.g., anterior communicating artery, posterior communicating artery, basilar artery tip]. Aneurysm size was measured at [Size in millimeters]. At the time of diagnosis, the patient presented with [Symptoms at time of diagnosis, e.g., sudden severe headache, double vision, stiff neck, loss of consciousness, seizures, or asymptomatic]. Subsequent management included [Treatment approach, e.g., microsurgical clipping, endovascular coiling, conservative management with serial imaging surveillance]. Current symptoms include [Current symptoms, e.g., headache, neurological deficits, or asymptomatic]. Patient reports compliance with prescribed medications, which include [List medications]. Neurological examination reveals [Neurological findings, e.g., cranial nerves intact, normal motor strength and reflexes, or specific deficits]. Risk factors for aneurysm development include [Risk factors, e.g., smoking, hypertension, family history of aneurysms, polycystic kidney disease]. Patient education provided regarding aneurysm rupture risk factors, signs and symptoms of subarachnoid hemorrhage, and importance of follow-up. Plan includes [Plan, e.g., continued surveillance imaging, follow-up with neurosurgery, lifestyle modifications for risk factor management]. ICD-10 code I67.1 (Cerebral aneurysm, non-ruptured) is applicable for ongoing monitoring. Differential diagnoses considered at initial presentation included [Differential diagnoses, e.g., migraine, cluster headache, meningitis]. Prognosis for long-term stability is [Prognosis, e.g., good with continued monitoring, guarded due to aneurysm location and size].