Home Health ICD-9/ICD-10 Alert

Time isn't the only factor to consider when looking at late effects codes.

If coding for traumatic brain injuries has you reaching for the aspirin, it's time to get past the myths and bone up on the basics.

While some coders are tempted to report neurological case mix codes 851 through 854, they aren't always appropriate primary diagnosis codes for home care.

Understand the 850-854 Series

Learn the differences between the intracranial injury codes, (850-854), suggests Dio Namocatcat, CCS, HCS-D, CPC with the Visiting Nurse Regional Health Care System in Brooklyn, NY:

• The 850.xx (Concussion) category refers to a cerebral bruising that may lead to a transient unconsciousness, often followed by amnesia, vertigo, nausea and weak pulse, says Namocatcat. Patients with this type of head injury are often dazed, and the physician may have to rely on clinical findings alone to make a diagnosis of concussion.

• You would not also assign an 850.xx code when the head injury is further described as a cerebral laceration, cerebral contusion, intracranial hemorrhage, or other specified condition classifiable to 851.xx (Cerebral laceration and contusion), 852.xx (Subarachnoid, subdural, and extradural hemorrhage, following injury) or 853.xx (Other and unspecified intracranial hemorrhage following injury). Categories 851-854 have a fifth-digit subclassification to indicate the level of consciousness associated with the injury; the fourth digit indicates whether there is an open wound, as well as providing more specific information about the type of injury, notes Namocatcat.

• You should not assign a code from category 854.xx (Intracranial injury of other and unspecified nature) along with any other code in the 850-853 series. Intracranial injury associated with skull injury is classified to fracture of the skull rather than to this series, says Namocatcat.

Caution: These codes are case mix diagnoses on the neurological list and are worth 20 points if they are the focus of care, says Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. However, often home care is not dealing with the head injury itself but the residuals of the head injury, she says.

Distinguish Late Effects From Acute Injury

There is no time limit on late effects. To differentiate between a patient suffering from the acute state of a traumatic injury versus a patient experiencing late effects, look for a break in service, says Keith Nielsen, RN, HCS-D, PPS/OASIS coordinator with Great Lakes Home Healthcare in Erie, PA.

For example: The patient who has suffered the initial injury and gone from hospital to rehab and then to an extended care facility for continuing therapy is still in the acute phase of the injury, says Nielsen.

If he then plateaus, returns home, and goes  through a period of time with no health care services, this is considered an interruption in service, explains Nielsen. If, two or three months later he starts to deteriorate, the patient is suffering the late effects of the injury, he says.
 
To determine whether to assign an acute or late-effects code, Nielsen suggests the following guidelines:
 
• If the treatment for the initial injury has been continuous since the onset, then do not use a late effects code--even if it's months down the road--because there has been a continuation of care. 

• If the care or services (not just home care but any services) have stopped because the patient has plateaued and then the problems start to manifest again, use a late effect code.

Tip: If the patient is in the acute state of traumatic brain injury, use that condition as primary, says Namocatcat. But if the brain injury is old and the reason for home care visits is cognitive deficits, then code it as follows:

• M0230a: 310.2 (Postconcussion syndrome) 
• M0240b: 907.0 (Late effect of intracranial injury without mention of skull fracture)

If the patient went for surgery to remove a blood clot or hemorrhage in the brain due to an injury, Namocatcat suggests reporting V58.43 (Aftercare following surgery for injury and trauma) in M0230a and entering the trauma code in M0245a.

Hint: To find the late effects codes, look up "late effect" in the alphabetic index. You will need to know the code for the acute injury to find the correct late effect code.

Knock Out Postconcussion Coding

If you're treating a patient for symptoms within 24 to 48 hours of an injury and the physician lists a diagnosis as postconcussion syndrome, ask the physician whether the concussion is still in the acute state and should be coded to 850.xx rather than 310.2 (Postconcussion syndrome) says Namocatcat. If the concussion is no longer in the acute state and the physician lists a diagnosis as postconcussion syndrome (late effect), then code this condition as primary, he says.

If the physician lists a diagnosis as memory disturbance (late effect), then code it as follows, says Namocatcat:
 
• M0230a 310.8 (Other specified nonpsychotic mental disorders following organic brain damage); and 

• M0240b 907.0 (Late effect of intracranial injury without mention of skull fracture).