Neurosurgery Coding Alert

Hint: Make sure you know whether patient lost consciousness or not.

When you’re reporting your physician’s concussion claims, do you know what details to look for in the medical documentation? Observe which ICD-10 codes are appropriate for you to report.

Answer the following questions to keep your concussion claims in tip-top shape.

Patient Never Lost Consciousness? Do This

Question 1: The patient, a football player, sustained a blow to his head during a game, and the physician diagnosed the patient with a concussion. But, looking through the notes, I see that the patient never lost consciousness. Can we report a concussion ICD-10 code if the patient didn’t lose consciousness? This was an initial encounter.

Answer 1: A patient does not have to be unconscious to code a concussion. The diagnosis should be made based on the patient’s symptoms and not on whether or not he is awake. If the physician documents that the patient has a concussion without losing consciousness, then you would look to the following codes:

• S06.0X0A (Concussion without loss of consciousness, initial encounter)
• S06.0X0D (… subsequent encounter)
• S06.0X0S (… sequela).

Note: The seventh character in the above codes indicates whether this is an initial, subsequent, or sequela encounter. In the case of the football player, since it was an initial encounter, you would report S06.0X0A. And, don’t forget to include W21.01XA (Struck by football, initial encounter) for the external cause code.

If Patient Loses Consciousness, Turn to These Codes

Question 2: The patient sustained a concussion after he was in a motor vehicle accident. According to the documentation the patient lost consciousness for 25 minutes. Which ICD-10 code should we report for this diagnosis? This was an initial encounter.

Answer 2: If the patient has a concussion where he loses consciousness for 30 minutes or less, you would look to the following codes:

• S06.0X1A
• S06.0X1D
• S06.0X1S

Remember: As with the ICD-10 codes where a concussion patient doesn’t lose consciousness, if he does lose consciousness, you must also use a seventh character that indicates whether this is an initial, subsequent, or sequela encounter. For the motor vehicle patient, you would report S06.0X1A since this in an initial encounter.

Duration Not Documented? Don’t Despair

Question 3: The patient fell off of a ladder while he was cleaning the gutters on his house. His wife brought him into the physician’s office. In the documentation, the physician does note that the patient has a concussion where he lost consciousness. However, the physician did not specify the duration of the patient’s unconsciousness and loss of awareness and responsiveness. Can we still report a concussion code even though we don’t have the specific time? This was an initial encounter.

Answer 3: Yes, you would report S06.0X9A in this situation. Code S06.0X9- applies when the physician does not indicate how long the concussion patient lost consciousness.