The most recent Coding Clinic (1st
Qtr. 2022) addressed the proper coding for Sunken Flap Syndrome. In this edition of “In the kNOW”,
we’ll explain what this condition is, the symptoms that patients may experience,
and the treatment available.
Sunken Flap
Syndrome is a condition that can occur after a patient has a craniectomy which
leaves them with a sizable skull defect.
For example, the craniectomy procedure may take place to decompress an
intracerebral hematoma or a hemicraniectomy may be performed to treat malignant
MCA (middle cerebral artery) infarction.
A picture is provided below to show the significant area impacted by
this syndrome.
Source: https://radiologykey.com/127-7/
Patients who
develop Sunken Flap Syndrome may have a variety of symptoms, principally
neurological in nature. This could be
headache, altered mental status, deficits related to speech and language, coma,
and even death. Some patients experience
seizures. The symptoms can occur soon
after surgery (within a week or two) or months later. Fortunately, the
incidence of Sunken Flap Syndrome is relatively rare.
The primary
treatment available to patients who suffer from this syndrome is a
cranioplasty. Previously, this was a
procedure that was delayed and performed mainly for cosmetic reasons. However, when patients with Sunken Flap
Syndrome undergo cranioplasty, there is often a significant improvement in
neurological function. Another treatment
that can help if a cranioplasty cannot be done immediately due to other medical
complications (i.e., pneumonia, meningitis, etc.) is posture-dependence. With this treatment, the patient is
positioned with the decompressed side downward until such a time as the
cranioplasty can be safely done.
The 1st
Qtr. 2022 Coding Clinic provided guidance for coding Sunken Flap
Syndrome. Two codes are necessary. First, G97.82, Other postprocedural
complications and disorders of nervous system should be assigned for the
complication as a result of the initial procedure. A second code of M95.2,
Other acquired deformity of head should then be assigned to capture the post
craniectomy Sunken Flap Syndrome. The second code is necessary since there is a
"use additional code" note at subcategory G97.8 which directs coding
professionals to assign additional codes to further specify the condition.
Now
you are In the kNOW!!
About the Author
Dianna Foley, RHIA, CHPS, CCS, CDIP is
OHIMA's Education Coordinator. Dianna has been an HIM
professional for 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.
