Neurosurgery Coding Alert

Remember to take into account late effects codes.

If you’re scratching your head when it comes to coding head injuries, you’re not alone. Particularly confusing is the management of concussion reporting. The solution? Examine what services the physician provided, and you will make your way closer to the best possible code.

1. Consider Procedure Code

Before you’ve got your diagnosis code nailed down, you should focus on the appropriate CPT® code to describe your service. If your physician provides an outpatient E/M service to evaluate the concussion, you’ll report the appropriate code from the 99201-99215 (Office or other outpatient visit …) series.

If you administer a computerized neuropsychological test to determine the impact of the concussion, report 96120 (Neuropsychological testing [e.g., Wisconsin Card Sorting Test], administered by a computer, with qualified health care professional interpretation and report).

If, however, your physician administered a non-computerized neuropsychological test, 96116 (Neurobehavioral status exam [clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities], per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report) would be an appropriate code.

If your physician performed both the neuropsychiatry testing and the E/M service at the same session, you can report both codes, assuming that your documentation can demonstrate the separate nature of the two services. In that case, you’ll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Often, concussion patients will return for follow-up visits. You can report the appropriate E/M code for these visits, unless the physician performs a different service besides an E/M one. For instance, if he saw the patient shortly after the concussion and the patient’s only symptom was blurred vision, the doctor might want to administer a vision test after two weeks pass. If the vision test is the only reason for the visit, you’ll report the appropriate code for that service.

2. Sort Out Minor Vs. Serious Injuries

If your physician is called in to see a patient with a head injury, you need to get straight what’s involved with coding these events from a diagnosis standpoint.

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.

3. Learn the Late Effects Codes

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.

“This can be helpful for the patient and insurer to track additional tests and treatment related to the initial injury,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. “It is also important to differentiate the late effects of one injury from a subsequent new acute injury, should one occur.”

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 pediatrician is seeing the patient, such as cognitive changes.

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. In pediatric patients, this is often residual dizziness or double vision following a concussion. “Other symptoms can include recurrent headaches, difficult maintaining attention, or learning disabilities,” says Przybylski.

Coding late effects generally requires two codes sequenced in the following order: first, the condition or nature of the late effect; and second, the late effect code. For instance, the condition code could be confusion (293.1, Confusion, subacute), followed by 907.0 (Late effect of intracranial injury without skull or facial fracture).

Reporting acute injury codes for all of the subsequent services for the latent/residual condition from a single injury indicates that the patient has had repeated acute injuries rather than requiring treatment/care for the delayed recovery of the initial injury.