AHA Coding Clinic® for ICD-9 - 2009 Issue 3; Ask the Editor

Malignant Brain Tumor with Cavernous Sinus Compression

A patient was admitted through the emergency department (ED) complaining of difficulty exhaling. He also reported experiencing strange smells during the past month. A computed tomography (CT) scan of the brain done in the ED showed a large mass in the right temporal lobe with a mass effect, pressing the right cerebral peduncle and compression of the cavernous sinus on the right side. Subsequent magnetic resonance imaging (MRI) revealed the same findings without surrounding edema. The consulting provider documents most likely slow-growing glioma. The provider's final diagnostic statement indicates newly diagnosed malignant brain tumor. Is it appropriate to assign a code for compression of the cavernous sinus as a secondary diagnosis? ...

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