Diagnosis coding of neurocognitive disorders.

Objective: Diagnosis coding is a core clinical competency. A basic understanding of the structure of the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), the conventions and rules for diagnosis coding, and what constitutes accurate coding, is fundamental to the clinician's knowledge base. This commentary seeks to provide a practical framework for clinicians to perform accurate diagnosis coding of neurocognitive disorders. Method: This paper: (1) summarizes the structure of the ICD-10-CM, (2) describes the rules and conventions of diagnosis coding for diagnostic categories relevant to neurocognitive disorders, (3) presents clinical examples and pragmatic recommendations to help readers improve their day-to-day use of diagnosis codes, and (4) describes limitations and discrepancies in the diagnosis coding advice for neurocognitive disorders presented within the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) and the DSM-5-TR Neurocognitive Disorders Supplement. Its content originates from the ICD-10-CM itself and its companion document, the ICD-10-CM Official Guidelines for Coding and Reporting. Conclusion: The ICD-10-CM classification scheme is logically organized and easy to navigate for users who understand its structure and rules. Many neuropsychologists rely on the DSM-5-TR diagnosis coding advice, however that advice is limited with respect to the range of diagnosis codes relevant to neurocognitive disorders and their underlying causes. Relying on the ICD-10-CM directly for diagnosis coding of neurocognitive disorders, rather than the DSM-5-TR or other secondary sources, is therefore preferable and aids clinicians in accurate diagnosis coding.

Optimizing cerebral oxygenation in cardiac surgery: A randomized controlled trial examining neurocognitive and perioperative outcomes.

OBJECTIVE: The study objective was to determine whether targeted therapy to optimize cerebral oxygenation is associated with improved neurocognitive and perioperative outcomes. METHODS: In a prospective trial, intraoperative cerebral oximetry monitoring using bilateral forehead probes was performed in cardiac surgical patients who were randomly assigned to an intervention group in which episodes of cerebral oxygen desaturation (<60% for >60 consecutive seconds at either probe) triggered an intervention protocol or a control group in which the cerebral oximetry data were hidden from the clinical team, and no intervention protocol was applied. Cognitive testing was performed preoperatively and at postoperative months 3 and 6; domains studied were response speed, processing speed, attention, and memory. Perioperative outcomes studied were death, hospital length of stay, intensive care unit length of stay, postoperative day of extubation, time on mechanical ventilation, intensive care unit delirium, Sequential Organ Failure Assessment on intensive care unit admission, and intensive care unit blood transfusion. RESULTS: Group mean memory change scores were significantly better in the intervention group at 6 months (0.60 [standard error, 0.30] vs -0.17 [standard error, 0.33], adjusted P = .008). However, presence, duration, and severity of cerebral desaturation were not associated with cognitive change scores. Perioperative outcomes did not differ between the intervention and control groups. CONCLUSIONS: Targeted therapy to optimize cerebral oxygenation was associated with better memory outcome in a group of cardiac surgical patients. Some aspects of the protocol other than desaturation duration and severity contributed to the observed neuroprotective effect.

ICD-10-CM Diagnosis Coding for Neuropsychological Assessment.

OBJECTIVE: This paper summarizes the basic principles of diagnosis coding for neuropsychological evaluation of patients with known or suspected brain injury or disease. METHOD: The resources forming the basis of this article are the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and the ICD-10-CM Official Guidelines for Coding and Reporting. CONCLUSION: Diagnosis codes are used to communicate the specific reason for health care encounters and the conditions treated. All health care providers in all health care settings are mandated to implement ICD-10-CM for coding all health care encounters and transactions. It is the providers of health care services who ultimately are responsible for medical record documentation and diagnosis coding. The neuropsychologist's knowledge base, therefore, should include a basic understanding of the structure of the ICD-10-CM, the conventions and rules for diagnosis coding, and the rules for what constitutes accurate coding.

Selective cerebral perfusion for thoracic aortic surgery: association with neurocognitive outcome.

OBJECTIVES: Optimal brain protection for aortic arch surgery remains unclear. This prospective study examined neurocognitive outcomes in cardiac and thoracic aortic surgical patients, including a small cohort who underwent selective cerebral perfusion. METHODS: Fifty-seven adult cardiac and thoracic aortic surgical patients underwent preoperative and postoperative neurocognitive testing. Patients were divided into 3 groups. Group 1 patients underwent procedures with cardiopulmonary bypass alone (n = 24), group 2 patients with cardiopulmonary bypass and hypothermic circulatory arrest (n = 23), and group 3 patients with cardiopulmonary bypass, hypothermic circulatory arrest, and anterograde selective cerebral perfusion (n = 10). Changes in 14 neurocognitive test scores and 6 neurocognitive domain scores (Attention, Speed, Language, Memory, Executive Function, and Motor Function) were evaluated. RESULTS: Multiple regression analyses examining the relationships of cardiopulmonary bypass time, hypothermic circulatory arrest time, and selective cerebral perfusion time with change in cognitive test performance revealed that selective cerebral perfusion time (range, 39-83 minutes) was a significant predictor of decline in performance on memory and language tests. Hypothermic circulatory arrest (range, 14-40 minutes) and cardiopulmonary bypass (range, 70-369 minutes) times were unrelated to decline. CONCLUSIONS: Complex thoracic aortic repairs requiring prolonged selective cerebral perfusion were associated with decline in neurocognitive function. It is unclear whether the complexity of the repair necessitating prolonged selective cerebral perfusion or the perfusion technique itself contributed to neurocognitive decline. Prospective multicenter neurocognitive evaluations are necessary to assess the relative merits of current brain protection strategies in thoracic aortic surgery.

Internet-based assessment of postoperative neurocognitive function in cardiac and thoracic aortic surgery patients.

OBJECTIVE: The primary purpose of this study was to determine the practicality of long-term, postoperative neurocognitive assessment via remote Internet-based testing in a cohort of patients who had undergone cardiac or thoracic aortic surgery within the previous 6 years. The secondary aim of this study was to examine the relationships among hypothermic circulatory arrest time, cardiopulmonary bypass time, and selective cerebral perfusion time with long-term postoperative neurocognitive function, as assessed by this novel testing method. METHODS: Three hundred patients who had undergone cardiac and/or proximal aortic surgery with cardiopulmonary bypass (n = 207), thoracic aortic surgery with hypothermic circulatory arrest (n = 67), or thoracic aortic surgery with hypothermic circulatory arrest and selective cerebral perfusion (n = 26) within the previous 6 years underwent Internet-based neurocognitive assessment. RESULTS: The duration of hypothermic circulatory arrest was negatively associated with processing speed scores and memory scores; arrest duration greater than 21 to 24 minutes was negatively associated with response speed scores. These associations were independent of time since surgery, age at testing, and educational level. Neither cardiopulmonary bypass duration nor selective cerebral perfusion duration was associated with test score results. CONCLUSIONS: This study demonstrated the practicality of long-term neurocognitive assessment of patients who have undergone cardiac and thoracic aortic surgery by means of Internet-based computerized testing. Furthermore, there was a negative association between the duration of intraoperative hypothermic circulatory arrest and long-term postoperative neurocognitive function that needs further examination in prospective studies.

Using jugular bulb oxyhemoglobin saturation to guide onset of deep hypothermic circulatory arrest does not affect post-operative neuropsychological function.

OBJECTIVES: Deep hypothermic circulatory arrest (DHCA) is commonly used during thoracic aortic surgery, and is initiated only after a sufficient degree of cerebral hypothermia is induced. The criteria for initiating DHCA vary among institutions: most centers use temperature criteria, some use electroencephalography, and a minority use jugular bulb oxyhemoglobin saturation SjO(2) criteria. The purpose of this study was to determine whether the use of SjO(2) monitoring to guide the onset of DHCA was associated with better post-operative neuropsychological outcome. METHODS: Sixty-one thoracic aortic surgical patients underwent both pre- and post-operative neuropsychological testing. Patients were divided into three groups: (1) those with SjO(2)> or =95% at DHCA onset; (2) those with SjO(2)<95% at DHCA onset; and (3) those without SjO(2) monitoring. RESULTS: There were no statistically significant differences in the incidence of post-operative decline in neuropsychological function among the three groups of patients. Patients in whom SjO(2) data were used to guide onset of DHCA had lower esophageal and bladder temperatures at that time compared with patients without SjO(2) monitoring. CONCLUSIONS: Monitoring of SjO(2) had no apparent effect upon post-operative neuropsychological outcome, and there were no trends in our small patient cohort suggesting differences that our study was not adequately powered to detect. Use of SjO(2) monitoring was associated with more profound hypothermia prior to DHCA due to more prolonged cooling in attempts to bring the SjO(2) above the 95% threshold. Using our institutional cooling protocol, SjO(2) monitoring does not appear to increase neuroprotection in patients undergoing DHCA for thoracic aortic repairs.