Home Health ICD-9/ICD-10 Alert

Question: Our patient fell from a ladder at home. He was admitted after being discharged from the hospital following craniotomy and evacuation of cerebral hemorrhage. His diagnosis is traumatic cerebral hemorrhage with brief loss of consciousness and open wound to the forehead. An X-ray showed no fracture.

Answer: Code for the acute head injury with a code from the in 850-854 (Intracranial injury, excluding those with skull fracture) range. In this case the agency is caring for late effects of the head injury, the gait abnormality, and the cognitive deficits. You're also providing aftercare of the surgical wound.

Which diagnosis you'll list as primary depends on whether the aftercare following surgery (V58.43) or the late effects (the cognitive deficits and abnormality of gait) are the focus of care.

If the late effects (residual deficits left after the acute injury has healed), are the focus of care, the correct late effects code is 907.0 (Late effect of intracranial injury without mention of skull fracture). The 907 category is a Neuro 1 case mix diagnosis.