EM Coding Alert

Question: Notes indicate that the provider performed a level-three office evaluation and management (E/M) service for an established patient. Final diagnosis was “postconcussional synd.” Is that a specific diagnosis, and what is “postconcussional synd”?

Answer: This note refers to postconcussional syndrome, which does have its own diagnosis code. On the claim, link F07.81 (Postconcussional syndrome) to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) to represent the patient’s condition.

Definition: According to Mayo Clinic, postconcussional syndrome involves “persistent post-concussive symptoms, … [and] occurs when concussion symptoms last beyond the expected recovery period after the initial injury. The usual recovery period is weeks to months. These symptoms may include headaches, dizziness, and problems with concentration and memory.”

According to Mayo Clinic, postconcussional syndrome is also called post-concussion syndrome. Further, ICD-10 lists these synonyms for postconcussional syndrome under the F07.81 heading:

• Postcontusional syndrome (encepha­lopathy)
• Post-traumatic brain syndrome, nonpsychotic.

Also: ICD-10 instructs coders to “Use additional code to identify associated post-traumatic headache, if applicable (G44.3-).”