Coding Tip: Understanding and Reporting Pseudoseizures
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
The latest edition of AHA, Coding Clinic for ICD-10-CM/ICD-10-PCS has given direction to coders on reporting the diagnosis of pseudoseizures. Let’s dig into this diagnosis a little to understand it better.
What Exactly is a Pseudoseizure?
Pseudoseizures are a form of non-epileptic seizure. These are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. The term “pseudoseizures” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES). One physician during this research had stated that this term should be regarded as jargon, but as coders, we still see “pseudoseizures” documented by physicians daily. These PNES appear to be epileptic seizures and a clear diagnosis is necessary for appropriate treatment.
Common Causes of Pseudoseizures/PNES
- Conversion disorder (medical condition where the brain and body’s nerves are not able to send and receive signals properly)
- History of sexual or physical abuse (PTSD)
- Anxiety disorders/panic attacks
- History of trauma or witnessing trauma (PTSD)
- Drug abuse
- Attention deficit hyperactivity disorder (ADHD)
- Anger repression or anger management issues
- Emotional disturbances
- Ongoing family conflicts
- Obsessive-compulsive disorder (OCD)
With the causes listed above, treating the patient’s underlying condition is the key to getting control of the attacks.
How is Pseudoseizure or PNES Diagnosed Over Epileptic Seizures?
OBSERVATION seems to be the best way to diagnose pseudoseizures in addition to video EEG monitoring. An EEG alone is helpful, but can often be normal in people with proven epilepsy. With the video EEG the physician is able to view the video of the activity as well as the brain during the actual attacks/seizure activity. There are many differences in the presence of epileptic vs. non-epileptic seizure activity. Below are just a few differences between the two. Keep in mind these are not present in every case.
|Pseudoseizure/Psychogenic nonepileptic seizure activity||Epileptic seizure activity|
|Closed eyes during episode||Open eyes during episode|
|Wild thrashing, side to side head movements and yelling during these episodes||This would represent diffuse cortical involvement and the patient would not be able to communicate during an epileptic episode involving all four extremities|
|Mouth clenched||Mouth is usually open during epileptic seizure|
|Being distracted by loud noise or stimulus during episode||During epileptic convulsion the patient should not startle or respond during an event|
|Normal activity after episode||Epileptic seizure typically leaves patient somnolent or confused for a period of time|
|Postictal normal breathing||Postictal deep, noisy breathing|
|No increase in heart rate during episode||Increase of heart rate up to 30% during episode|
With video EEG, the physician is able to view all of the symptoms that are associated with the attack/seizure to help determine the diagnosis.
Is the Treatment the Same?
NO! The treatment will be different if the patient isn’t suffering from epileptic seizures. Treating someone with pseudoseizures as if they have epileptic seizures can be very dangerous. When presenting with seizure activity, if treated as having epileptic seizure, the patient may be administered massive doses of antiepileptic drugs trying to calm the seizure activity. This can result in impaired consciousness and/or respiratory failure. There are also many other adverse effects that can be caused by the use of antiepileptic medications.
Treatment for non-epileptic seizures/pseudoseizures, will require the treatment of the underlying mental condition as well as physician monitoring (usually multiple physicians) and therapies.
Most patients respond to the news of pseudoseizure/PNES diagnosis with disbelief, denial, confusion, anger, doubt, sadness, or relief. Patients feel that this diagnosis labels them as crazy or insane, but that is absolutely not the case. There are only about 10% of the patients diagnosed with this feigning illness. Per Dr. Benbadis, this is a real condition that arises as a response to real stressors and the seizures are not consciously being produced and are not the patient’s fault.
Coding the Diagnosis of Pseudoseizure in ICD-10-CM
Per the recent Coding Clinic cited above, a diagnosis of pseudoseizure without mention of conversion disorder is coded to R56.9, Unspecified convulsions. If a patient has a history of seizures and a current admission with diagnosis of pseudoseizures, the physician should be queried to clarify if this represents recurrent seizure vs. pseudoseizure.
Interesting Statistics for PNES/Pseudoseizure Diagnosis
- 5% to 20% of patients diagnosed with PNES/pseudoseizures may also have epileptic seizures
- 30% to 50% of patients with PNES/pseudoseizures have been incorrectly diagnosed and admitted to an ICU
- 20% to 50% of patients stop having PNES/pseudoseizures once the diagnosis is reached and without any specific or new treatment
- Around 20% to 40% of the patients that attend epilepsy centers for EEG monitoring are having PNES/pseudoseizures rather than epileptic seizures
- At least 25% of people who have a previous diagnosis of epilepsy and are not responding to drug therapy are found to have been misdiagnosed
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Page: 3
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Did you get a chance to read the FY2022 IPPS Final Rule? There is an interesting topic that was discussed regarding unspecified ICD-10-CM laterality diagnosis codes, to be exact. In this coding tip we discuss that subject and possible ramifications of it in the coding world.
In Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments. Prepare yourself as this is rather lengthy due to continuation of NTAP that would normally expire.
Coders are instructed, at this time, to follow the AHA Frequently Asked Questions Regarding ICD-10-CM/PCS Coding for COVID-19. Lately, we have seen missing PCS codes for the new technology drugs that were introduced on August 1, 2020 and thereafter.
With the creation and implementation of ICD-10-CM, multiple codes are available to describe the type of pulmonary emboli that occur.
Hypercoagulable states are blood disorders that increase the risk of deep vein thrombosis or embolic disease. The state is either inherited or acquired. About 80% of patients with blood clots have been found to have either an inherited or acquired clotting disorder. These blood clots can be lethal and some require life-long therapy. Hypercoagulable state is also known as thrombophilia.
Encephalopathy is a general term and means brain disease, brain damage or malfunction. Physicians often use encephalopathy and altered mental status interchangeably. When coders see this documentation in the healthcare records, they typically need to query the physician for clarification of the diagnosis.
Spinal procedure coding can be daunting for coders. The spine itself can be quite complicated anatomically and the procedures done to address spinal conditions can be even more complicated!
In June CMS released the final ICD-10-PCS codes for FY2022, which begins October 1, 2021. We are giving you a sneak peek at the changes. HIA will have a full educational module on these changes available later this summer.
CMS released the IPPS proposed rule on 4/27/21 outlining the proposed changes to the Inpatient Prospective Payment System for FY2022, which begins October 1, 2021. Later this year, sometime in August, CMS will release the Final Rule. Currently CMS is reviewing responses to their proposed rule and will address them in the final rule.
A medical coding audit is a process that includes internal or external reviews of medical coding and billing accuracy, procedures or policies in place, and any other component that affects the medical record documentation. Medical coding audits…
Anticoagulants and antiplatelets are used for the prevention and treatment of blood clots that occur in blood vessels. Oftentimes, anticoagulants and antiplatelets are referred to as “blood thinners,” but they don’t actually thin the blood at all. These drugs slow down the body’s process of making clots. Their main function is to keep the patient’s blood from clotting or turning into solid clumps of cells. These drugs do this by interfering with either fibrin or platelets in the blood.
Carotid artery disease is a vague category that can incorporate many different carotid artery issues. Some physicians may feel that they are being clear the patient has plaque, stenosis, or occlusion of the artery, but in ICD-10-CM the specificity must be included in the documentation.
10 ICD-10 Codes for Superheroes. Superman: T78.2XXA Anaphylactic reaction; substance: kryptonite. Batman: F44.81 Dissociative identity disorder. Robin: F60.7 dependent personality. The Hulk: L30.4 Erythema intertrigo. Wonder Woman: T24.032A Burn of unspecified degree of left lower leg. Black Panther S93.401A Sprain…
Practices have not seen many revisions to the Evaluation and Management (E/M) office / outpatient visit guidelines in three decades – until now. As of January 1, there are new E/M coding guidelines. We’ll get to those in a bit, but first let’s look at why they changed.
With the implementation of ICD-10-CM came different codes and coding rules for many diagnoses. One of these is the coding of bowel obstruction when the patient presents for this condition that is caused by another condition.
This is Part 5 of a five part series on the new 2021 CPT codes. For the remaining areas we will just briefly summarize the section. Due to the intricate nature of these sections in CPT, it is recommended that the coder read the entire section notes associated with the new codes.
This is Part 4 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes in the urinary, nervous, ocular and auditory systems. There are 2 new urinary/male reproductive system codes with no revisions or deletions; 3 new female reproductive codes with 2 deletions, 0 new with 4 deleted nervous system codes with 5 revisions; 5 new eye category III codes; and finally a 2 new auditory codes with one deletion.
This is Part 3 of a five part series on the new 2021 CPT codes. In this series we will explore the cardiovascular system CPT changes. There are 5 new cardiovascular CPT codes added with 0 deletions and 4 revisions.
This is Part 2 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include some examples to help the coder understand the new codes. There are 0 new musculoskeletal CPT codes added with 0 deletions and 2 major revisions along with an extensive update to arthroscopic loose body removal requirements. For the respiratory system, there were 2 new codes, one code deletion and no revisions.
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.