Neurology & Pain Management Coding Alert

Question: What diagnosis should we use for traumatic brain injury? Is -concussion with loss of consciousness- our only choice?

Oregon Subscriber

Answer: The best code depends on your physician's documentation. Selecting a -loss of consciousness- code, such as 850.2 (Concussion; with moderate loss of consciousness), could work, but report a more specific code whenever possible. Many coders recommend 854.0x (Intracranial injury of other and unspecified nature; without mention of open intracranial wound). If you choose this code, be sure to include the appropriate fifth digit to explain the loss of consciousness.

Depending on the case, you might want to read through the entire section for -Intracranial injury, excluding those with skull fracture- (850.x-854.x) to ensure you don't overlook a more specific diagnosis such as brain laceration (851.x, Cerebral laceration and contusion) or an injury with hemorrhage (852.x, Subarachnoid, subdural and extradural hemorrhage, following injury).

After selecting the best diagnosis code, remember to include an E code to explain the cause of injury.