Billing and Coding for Cerebral Edema and Brain Compression

If Cerebral Edema or Brain Compression is clinically significant, it adds to the severity of illness and risk of mortality. It:

• Must be documented by a provider caring for the patient
• Document link to underlying condition: neoplasm, CVA, SDH, trauma, other

Note: "Mass effect" and "Midline shift" do not equal "cerebral edema" or "brain compression". They cannot be used interchangeably and will not add to the complexity of the patient. There is no ICD 10 code for mass effect or midline shift. Document cerebral edema or brain compression when it is clinically significant, receiving treatment, or being monitored.

e.g. "left hemispheric acute SDH with mass effect" or "left hemispheric acute SDH with brain compression"