Neurology & Pain Management Coding Alert

Question: Which diagnosis code should we report when a traumatic brain injury (TBI) causes cognitive deficits? We can't find anything in the ICD-9 manual that addresses this.

Alaska Subscriber

Answer: Most coders report 294.9 (Unspecified persistent mental disorders due to conditions classified elsewhere) for this diagnosis, although they complain that its nonspecific nature can invite denials.

What it is: -Cognitive deficit- means the patient has difficulties in reasoning, judgment, intuition and memory, and lack of awareness and insight, whereas one definition for -cognitive impairment- is deficiency in ability to think, perceive, reason or remember, resulting in loss of ability to attend to one's daily living needs.

Best bet: You should have your neurologist clearly document what the patient has specific problems performing -- such as memory or lack of insight.

Option 1: If the physician documents a specific problem due to brain damage, you may be able to classify the condition using a code from the 310.1-310.9 range. Although these codes are in the mental disorders section, the subsection 310.x is clearly for nonpsychotic mental disorders due to brain damage.

Option 2: Others opt to use the associated dementia code (294.8), thinking that their documentation supports a more specific diagnosis than the -unspecified- for 294.9.

On the other hand, these codes do fall under the section of persistent mental disorders due to conditions classified elsewhere, and in most cases this qualifies as coding -close- rather than coding the patient's actual condition. Without additional information, rather than coding close, you should choose the nonspecific code.

Keep in mind: ICD-9 also includes 331.83 (Mild cognitive impairment). But this isn't a solution for the TBI cognitive deficit patients because the exclusions include cerebral degeneration (331.0-331.9), change in mental status (780.97), cognitive deficits following (late effects of) cerebral hemorrhage or infarction (438.0), cognitive impairment due to intracranial or head injury (850-854, 959.01), cognitive impairment due to late effect of intracranial injury (907.0), dementia (290.0-290.43, 294.8), mild memory disturbance (310.8), neurologic neglect syndrome (781.8), and nonpsychotic personality change (310.1).