Neurosurgery Coding Alert

TBI treatments range from medication to major surgery.

When a patient suffers a traumatic brain injury (TBI), they’ll often end up at a neurosurgeon’s office for treatment.

How the surgeon treats the TBI will be entirely patient-dependent. There are some TBIs that won’t require surgical intervention; if surgery is needed, however, there are many options for treatment.

Check out this rundown of the most common TBI treatments, along with a clinical example from an industry expert.

Exam Might Lead to Medication Regimen

One option for treatment of a confirmed TBI is medication; generally speaking, these medications could include:

• Analgesics for pain management
• Anticonvulsants to prevent or control seizures
• Diuretics/hyperosmotic agents to reduce brain swelling
• Anti-anxiety or antidepressant medications to address psychological symptoms
• Stimulants or medications for attention and cognitive deficits
• Medications to manage other specific symptoms such as sleep disturbances or muscle spasticity

Consider this example from Gregory Przybylski, MD, MBA, Chairman of Neuroscience at the Hackensack Meridian Health Neuroscience Institute at JFK University Medical Center in Edison, New Jersey

A 35-year-old patient sustained a diffuse TBI with less than 30 minutes loss of consciousness associated with diffuse traumatic subarachnoid hemorrhage several months ago that was managed nonoperatively elsewhere. They complained of persistent headaches to their primary care physician (PCP), who recommended evaluation by a neurosurgeon for possible posttraumatic hydrocephalus. The neurosurgeon performs a level-four new patient evaluation and management (E/M) service. Review of a prior magnetic resonance imaging (MRI) during the E/M confirms evidence of TBI. The neurosurgeon orders a follow-up computed tomography (CT) of the head without contrast that rules out hydrocephalus.

For this encounter, you would report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the E/M, with S06.2X1A (Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, initial encounter) and S06.6X1A (Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter) appended to represent the patient’s TBI and hemorrhage. (The radiologist would report the codes for the CT.)

Surgery Often Necessary With These TBI Types

In cases of severe TBI with significant bleeding, swelling, or skull fractures, surgery may be necessary to alleviate pressure on the brain, remove blood clots, repair damaged blood vessels, or address other structural issues.

Here’s a few examples of TBIs that could require surgery, and the surgical intervention that they require:

• Contusion/hematoma: If the TBI features significant brain bruising or hematoma, surgery may be required to remove the clot or repair damaged blood vessels.
• ICP management: TBI patients can also suffer elevated intracranial pressure (ICP) due to brain swelling or bleeding. If the surgeon cannot control ICP using conservative measures and medication, they might perform surgery, such as a decompressive craniectomy.
• Skull fractures: If the TBI is accompanied by a severe skull fracture, it might require surgery to stabilize the bone fragments and reduce the risk of infection or injury to the underlying brain tissue.
• Penetrating trauma: If the TBI patient suffered a gunshot wound or a stab injury, the surgeon might operate to remove foreign objects, repair damaged tissue, or control bleeding.
• Skull decompression: If the TBI’s swelling or bleeding puts the brain at risk of herniation, the surgeon might remove a portion of the skull to relieve pressure and allow the brain to expand without compression.

Caveat: If the patient suffers TBI along with other injuries, be sure to choose a diagnosis code for the TBI and for the accompanying injury. For example, if the patient has a diffuse TBI with 36 minutes loss of consciousness and crushing injury of the skull, you’d report S07.1- (Crushing injury of skull) and S06.2X2- (Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes). When reporting multiple diagnosis codes, the first diagnosis code to report should be the primary reason for the evaluation/management and/or procedural service.