EPILEPSY. An overview of issues important in documentation

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1 EPILEPSY An verview f issues imprtant in dcumentatin Cmpiled by: Launa Fackrell - Clinical Dcumentatin Imprvement Manager Letitia Sammns, MBA, RHIT Clinical Dcumentatin Imprvement Specialist Crystal Pwell, RN, BSN, CPN Clinical Dcumentatin Imprvement Specialist Health Infrmatin Management Children s Health System f Texas Apprved by: Susan Iannaccne, MD Divisin Directr Neurlgy Susan Arnld, MD Physician Champin Neurlgy Juanita Dale, Ph.D., RN, CPNP-PC Subject Matter Expert Neurlgy Kelly Butler, MPAS, PA-C- Subject Matter Expert Neurlgy HIM/HER Cmmittee Apprved by: Katherine Lusk, MHSM, RHIA Chief Health Infrmatin & Exchange Officer Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 1

2 Issue: 1. Lack f clarity in defining intractable epilepsy leading t incnsistent dcumentatin 2. Prviders using terms such as seizure and epilepsy interchangeably 3. Failure t specify type f epilepsy in dcumentatin i.e. intractable epilepsy with partial fcal cmplex seizures Initial Premise: 1. In this dcument, the gal is t achieve cnsensus n a clinical definitin fr intractable epilepsy as it pertains t ur pediatric ppulatin. 2. Dcumenting intractable epilepsy and capturing the apprpriate ICD 9/ICD 10 cdes will result in a case mix index that accurately reflects patient acuity. 3. Dcumenting seizures and epilepsy with greater specificity allws fr a mre specific ICD 9/ICD 10 cde assignment. Intractable Epilepsy Dcumentatin Descriptin f the prblem: Review f the medical recrds reveals incnsistency with defining intractable epilepsy in patient recrds acrss all disciplines, resulting in a case mix index that is nt reflective f resurce cnsumptin and patient acuity. The recrd reviews als shw prviders at times nly dcumenting seizures when the patient in fact carries a diagnsis f epilepsy. There is als a lack f specificity in dcumenting the specific type f seizures. In this dcument, we seek t bring clarity t these issues and imprve clinical dcumentatin. The Neurlgy Divisin served as the leading discipline mst clsely aligned with these cnditins. While vetting the definitin fr intractable epilepsy, ur Neurlgists expressed the need t include criteria fr prly cntrlled epilepsy as well. Cnclusin- An agreement was reached regarding a standardized clinical definitin fr intractable epilepsy as fllws: Intractable Epilepsy is defined as persistent seizures in an epileptic child, despite adequate trials with 2 Anti-Epileptic Drugs (AEDS). There are three main treatments used fr medically intractable epilepsy: Ketgenic Diet, Epilepsy Surgery, and Vagus Nerve Stimulatr (5). *Please nte the fllwing terms are t be cnsidered equivalent t Intractable Epilepsy - Pharmacresistant; Treatment resistant; Refractry; Prly cntrlled. Intractable epilepsy, r an equivalent term, shuld be dcumented when present t accurately reflect severity f illness. Children s Health Neurlgists define Prly Cntrlled Epilepsy as characterized by the presence f breakthrugh seizures in a knwn epileptic patient. Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 2

3 Intractable Epilepsy Literature Review Much f the literature is fairly cnsistent in their definitin f intractable epilepsy including the failure t respnd t adequate trials f at least 2 Anti-Epileptic Drugs (AEDs). Please nte the fllwing terms are t be cnsidered equivalent t Intractable Epilepsy and are ften used interchangeably thrughut the literature: pharmacresistant, treatment resistant, refractry, and prly cntrlled. The May Clinic indicates that ne in 5 children with epilepsy has intractable seizures and further defines intractable epilepsy as seizures that fail t respnd t at least tw apprpriate anti-seizure medicatins (7). The Natinal Institute f Health defines medically refractry epilepsy as epilepsy that des nt get better after tw r three anti-seizure drugs have been tried (11). A cnsensus statement by the Natinal Institute f Health states, By intractable we mean that seizures have nt been brught under acceptable cntrl with the resurces available t the primary care physician r neurlgist (12). An article by the Epilepsy Fundatin, includes a prpsed definitin f drug resistant epilepsy by Internatinal League Against Epilepsy (ILAE), as a persn has failed t becme (and stay) seizure free with adequate trials f tw seizure medicatins (called AEDs) (9). The University f Pittsburgh defines medically intractable epilepsy as persistent seizure activity, which, despite maximal medical treatment, remains sufficiently debilitating t warrant the risks f surgery (8). The Iran Jurnal f Child Neurlgy, states it is estimated abut 20-30% f patients becme refractry t medical therapy (13). There are sme surces that suggest adequate therapy with 3 r mre AEDs in their definitin f intractable epilepsy (13). Hwever, in an article abut pharmaclgically intractable epilepsy, the Neursurgical Fcus Jurnal indicates that when 2 AEDs fr the crrect seizure type and in adequate dses fail there is nly a 5-10% prbability f achieving seizure cntrl with a third drug (10). Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 3

4 Seizures and Epilepsy Literature Review The American Academy f Pediatrics defines seizures as sudden temprary changes in physical mvement, sensatin, r behavir caused by abnrmal electrical impulses in the brain. The terms cnvulsin and seizure can be used interchangeably (1). In ther wrds, a seizure is a transient ccurrence f signs and/r symptms resulting frm abnrmal excessive r synchrnus neurnal activity in the brain (2). Characteristics f seizure can be fund n Table 1 f the Appendix. It is imprtant t nte that a first seizure might present as status epilepticus (4). Status epilepticus is a medical emergency defined as cntinuus seizure activity r recurrent seizure activity withut regaining f cnsciusness lasting fr >30 min (2). Accrding t Nelsn s Textbk f Pediatrics, apprximately 30% f patients wh have a first afebrile seizure have later epilepsy (2). Epilepsy is a disrder f the brain characterized by an enduring predispsitin t generate epileptic seizures, and by the neurbilgic, cgnitive, psychlgical, and scial cnsequences f this cnditin. The definitin f epilepsy requires the ccurrence f at least ne epileptic seizure (4). Epilepsy is disease f the brain defined by any f the fllwing cnditins (4): At least tw unprvked (r reflex) seizures ccurring >24 hurs apart One unprvked (r reflex) seizure and a prbability f further seizures similar t the general recurrence risk f (at least 60%) after tw unprvked seizures, ccurring ver the next 10 years Diagnsis f an epilepsy syndrme Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 4

5 Tips fr Dcumentatin Step 1: Dcument intractable epilepsy r an equivalent term when applicable (i.e. 2 AEDs, Vagus Nerve Stimulatr, Ketgenic Diet, and/r Surgical Candidate). *Equivalent terms include: pharmacresistant; treatment resistant; refractry; prly cntrlled *Cnsider prly cntrlled epilepsy fr epileptic patients presenting with breakthrugh seizures. Step 2: Dcument the type f epilepsy (i.e. simple fcal, cmplex fcal, absence, tnic, clnic, myclnic, atnic, etc.). *When dcumenting, it is imprtant t be as specific as pssible. Specific dcumentatin is nt nly necessary fr clinical cmmunicatin but als results in prper cde assignment. One such example f mre specific dcumentatin wuld be t specify the type f epilepsy being treated r managed (i.e. Patient is admitted with epilepsy vs. Patient is admitted fr prly cntrlled epilepsy with fcal cmplex seizures). Examples f the types and causes f epilepsy can be fund n Table 2 f the Appendix. Nt specific Mre Specific Mst Specific Patient admitted with epilepsy. Patient admitted fr prly cntrlled epilepsy. Patient admitted fr prly cntrlled epilepsy with fcal cmplex seizures. Clinical Dcumentatin Imprvement Specialists lk fr: TYPE: DETAIL: UNDERLYING CAUSE: CLINICAL INDICATORS: Epilepsy, withut mentin f intractable; Prly Cntrlled Epilepsy; Intractable Epilepsy; Pharmacresistant Epilepsy; Treatment-Resistant Epilepsy Further specificity f type f epilepsy (i.e. partial vs. generalized) Structural r Acquired prblems Medicatins Antiepileptics Patient admitted fr initiatin f the Ketgenic Diet r Surgical Evaluatin Patient has r is admitted fr placement f Vagal Nerve Stimulatr Administratin f Rescue Antiepileptics fr prlnged seizure episde Patient admitted fr breakthrugh seizures Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 5

6 Assignment f an ICD 10 Cde Cde Assignment fr Seizure and Epilepsy in ICD-10-CM (6): Cding fr seizures and epilepsy in ICD-10-CM is similar t ICD-9-CM. ICD-10-CM categry G40 is titled Epilepsy and recurrent seizures. The fllwing are the furth character subcategries fr epilepsy: G40.0, Lcalizatin-related (fcal) (partial) idipathic epilepsy and epileptic syndrmes with seizures f lcalized nset G40.1, Lcalizatin-related (fcal) (partial) symptmatic epilepsy and epileptic syndrmes with simple partial seizures G40.2, Lcalizatin-related (fcal) (partial) symptmatic epilepsy and epileptic syndrmes with cmplex partial seizures G40.3, Generalized idipathic epilepsy and epileptic syndrmes G40.A, Absence epileptic syndrme G40.B, Juvenile myclnic epilepsy [impulsive petit mal] G40.4, Other generalized epilepsy and epileptic syndrmes G40.5, Epileptic seizures related t external causes G40.8, Other epilepsy and recurrent seizures G40.9, Epilepsy, unspecified The abve subcategries are mainly separated by lcalized vs. generalized There are separate cdes if the epilepsy is idipathic vs. symptmatic The fifth and sixth characters will identify the presence r absence f status epilepticus and intractable epilepsy *Nte: In ICD-10-CM the fllwing terms are t be cnsidered equivalent t intractable: pharmacresistant, treatment resistant, refractry and prly cntrlled Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 6

7 Case Study Neurlgy Case Study Befre: Histry f Present Illness: 3-year-ld patient with knwn epilepsy and develpmental delay admitted with breakthrugh seizures. His mther brught him t Children s ED with histry f fur seizures and decreased respnsiveness. Upn admissin, he was laded with levetiracetam 30 mg/kg and cntinued n maintenance ral dse f levetiracetam 30 mg/kg. Befre Questin After DRG 053 Seizure Review f the medical recrd prgress nte DRG 053 Seizure Severity Weight dated 10/01/2014 indicates "breakthrugh seizures". The treatment prtcl is shwing Severity Weight Principal Epilepsy, withut 325 mg Keppra IV. Can yu clarify if, fr this Principal Diagnsis Prly Cntrlled Epilepsy Diagnsis intractable epilepsy admissin, yu are currently treating prly cntrlled epilepsy? Secndary Diagnsis Develpmental Delay Dcumentatin t Impact Severity f Illness Secndary Diagnsis Develpmental Delay Severity f Illness Level Mderate Yes, the patient has prly cntrlled epilepsy Severity f Illness Level Increased Majr Shuld be: Histry f Present Illness: 3-year-ld patient with knwn epilepsy and develpmental delay admitted with breakthrugh seizures in the setting f prly cntrlled epilepsy. His mther brught him t Children s ED with histry f fur seizures and decreased respnsiveness. Upn admissin, he was laded with levetiracetam 30 mg/kg and cntinued n maintenance ral dse f levetiracetam 30 mg/kg. Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 7

8 Appendix Table 1 Characteristics f a Seizure may include (3): jerking mvements r stiffening f the arms and legs smacking f the lips, twitching f the face, r the child picking sudden lss f muscle cntrl r staring spells drling, drping f ne side f the face, blue clr f the lips r face change in breathing pattern a perid f extreme sleepiness afterwards Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 8

9 Table 2 Types f Epilepsy: There are tw main categries f epilepsy: partial (als called lcal r fcal) and generalized (6). Partial seizures ccur in nly ne part f the brain. The fllwing are tw cmmn types f partial epilepsy: Simple fcal seizure - awareness is retained and des nt result in lss f cnsciusness. It may alter emtins r change the patient s senses, such as taste r smell. Cmplex fcal seizure - alters cnsciusness resulting in staring r nnpurpseful mvements such as hand rubbing, chewing, lip smacking, and walking in circles. Generalized seizures invlve all parts f the brain. The fllwing are the six types f generalized seizures: Absence seizures (petit mal) - characterized by blank staring and subtle bdy mvements that begin and end abruptly. It may cause a brief lss f cnsciusness. Tnic seizures - causes stiffening f the muscles and may cause the patient t fall t the grund. Clnic seizures - characterized by rhythmic, jerking muscle cntractins that affect bth sides f the bdy at the same time. Myclnic seizures - assciated with sudden brief jerks r twitches n bth sides f the bdy. Atnic seizures - causes patients t lse muscle tne, s they subsequently cllapse. Tnic-clnic seizures (grand mal) - mst intense type f epilepsy causing lss f cnsciusness, muscle rigidity, and cnvulsins. Causes f Epilepsy in children can include (2): Drug intxicatin in children Drug and alchl abuse in adlescents Drug withdrawal r verdse in patients n AEDs Hypglycemia Electrlytes imbalance (hypcalcemia, hypnatremia, hypmagnesemia) Acute head trauma Encephalitis Meningitis Ischemic (arterial r venus) strke Intracranial hemrrhage Inbrn errrs f metablism Hypxic-ischemic injury Systemic cnditins Brain tumrs Brain malfrmatins Neurdegenerative disrders Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 9

10 References 1. American Academy f Pediatrics. (2014). Seizures, Cnvulsins, and Epilepsy. Retrieved May 21, 2014, frm 2. Mikati, M. (2013). Seizures in Childhd. In Nelsn Textbk f Pediatrics. 19th Ed. (pp ) Philadelphia, PA: Elsevier Saunders. 3. Cincinnati Children s. (2013). Epilepsy and Seizures. Retrieved May 15, 2014, frm 4. Fisher, R., Aceved, C., Arzimanglu, A., et al. (2014). A practical clinical definitin f epilepsy. ILAE Official Reprt: 1-8. Retrieved April 30, 2014, frm 5. Miami Children s Brain Institute. (2008). Intractable Epilepsy. Retrieved May 14, 2014, frm 6. Cding fr Seizures and Epilepsy. (2012). Fr The Recrd. 24(10), May Clinic. (2014). Surgical management f intractable seizures in children with epilepsy. Retrieved May 14, 2014, frm 8. University f Pittsburgh. (2014). Pediatric Epilepsy: Medical Intractability. Retrieved Nvember 10, 2014, frm 9. Epilepsy Fundatin. (2014). Refractry Epilepsy. Retrieved Nvember 10, 2014, frm G, C., & Snead, C. (2008). Pharmaclgically Intractable Epilepsy in Children: Diagnsis and Preperative Evaluatin. Neursurg Fcus. 2008; 25(3):E Epilepsy. (2012). In MedlinePlus. Retrieved May 29, 2014, frm Natinal Institutes f Health. (1990). Surgery fr Epilepsy. (1990). In Natinal Institutes f Health Cnsensus Develpment Cnference Statement March 19-21, (2), Ghfrani, M., & Akhndian, J. (2010). Intractable Epilepsy in Children. Iran Jurnal f Child Neurlgy 4(3) Children s Health System f Texas cpy f this dcument may be fund n CMC ChildNet/Physician Training/Clinical Dcumentatin Imprvement/CDI Definitins Updated February 2016 Page 10