4 Tips Help You Code Head Injuries
Published on Fri Sep 22, 2006
Learn what options you have for cognitive deficits
Scanning your ICD-9 coding manual for an appropriate diagnosis code can mean a headache. You probably won't find a perfect code, but here's how to get closer than ever before. Sort Out Minor Versus Serious Injuries If your neurologist is called in to see a patient with a head injury, you need to get straight what's involved with coding these events.
Minor injuries: If the patient has a contusion of the head, you should use 920 (Contusion of face, scalp, and neck except eye[s]), but remember that a contusion, by definition, includes a bruising injury that does not break the skin. You should check for exclusions in your ICD-9 book. The exclusion note for 920 refers to various other codes for more significant injuries that go beyond a basic bump on the head.
When your provider doesn't document any further detail than -head injury,- you should use 959.01 (Head injury, unspecified). This code also has a list of exclusions similar to 920.
Significant injuries: You should report codes from the 850-854 series, including 854.01 (Intracranial injury of other and unspecified nature; without mention of open intracranial wound; with no loss of consciousness), for other specific and serious injuries involving the head, such as concussions, cerebral lacerations, cerebral contusions, and open wounds with brain hemorrhage. This series represents very serious injuries resulting from high-energy impacts to the head. Specifically, the 854 set includes cavernous sinus and intracranial injury.
-We use 854.01 for total brain injury (TBI),- says Deborah Cox, CPC, MA, coding consultant and supervisor at Physician Practice Management in Bangor, Maine. Learn the Late Effects Code If the patient had a brain injury more than a year ago, you should look to a late effects code. Using a late effects code creates the causality relationship between a prior injury and the current condition your provider is treating, says Marvel Hammer, RN, CPC, CCS-P, CHCO, owner of MJH Consulting in Denver.
A possible example is 907.0 (Late effect of intracranial injury without mention of skull fracture). In addition, you want to code as primary the actual residual condition for which the neurologist is seeing the patient, such as cognitive, neuropsych or functional changes, Hammer says.
What it is: A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has ended. There is no time limit on when you can use a late effect code. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury.
Coding late effects generally requires two codes sequenced in the following order: first, the condition or nature of the [...]
