Neurosurgery Coding Alert

Caution: More than one ICD-9 code may map to the same ICD-10 code.

When reporting contusions of cerebral cortex with no open wound, you can make your way to the right code by looking for the duration of loss of consciousness. ICD-10 offers you a direct match for cerebral contusions with no open wounds. However, you have an exception too. Here is how you can easily navigate to the right codes. 

Consciousness not documented: Your physician may not document the state of consciousness for a patient with cerebral contusions with no open wound. In this case, you report ICD-9 code 851.00 (Cortex [cerebral] contusion without open intracranial wound state of consciousness unspecified) which maps to ICD-10 code S06.330A (Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial encounter).

Spot the difference: The ICD-10 code S06.330A has a clearer descriptor stating that there was no loss of consciousness. The ICD-9 code 851.00, on the other hand, states that consciousness wasn’t specified. 

Also note that ICD-9 code 851.09 (Cortex [cerebral] contusion without open intracranial wound with concussion unspecified) maps to two codes in ICD-10, i.e. S06.330A and S06.339A (Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter) depending upon whether or not the patient lost consciousness. 

Revisit the Duration of Unconsciousness Documented

There are three codes that you need to consider when reporting the duration of unconsciousness for cerebral contusion without open wound. These have been tabulated in table 1 for easy reference.

Note the revisions: ICD-10 introduces new range for duration of loss of consciousness. You no longer distinguish ‘brief’ and ‘moderate’ loss of consciousness. ICD-9 code 851.02 which applies for brief loss of consciousness with duration of less than one hour maps to ICD-10 code S06.331A which applies to loss of consciousness of 30 minutes or less. Similarly, ICD-9 code 851.03 defines moderate loss of consciousness as that which ranges from 1-24 hours and the corresponding ICD-10 code S06.333A applies for loss of consciousness of 1 hour to 5 hours 59 minutes.

Find Specific Codes When Duration of Unconsciousness is Not Documented

When your physician does not document the duration of loss of consciousness, you can submit ICD-9 code 851.06 (Cortex [cerebral] contusion without open intracranial wound with loss of consciousness of unspecified duration) which corresponds to ICD-10 code S06.339A (Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter).

Also note: ICD-9 code 851.01 also maps to S06.339A in ICD-10. While ICD-9 code 851.01 is appropriate for cortical contusion without open intracranial wound with no loss of consciousness, the corresponding ICD-10 code S06.339A applies to loss of consciousness of unspecified duration.

Do Not Forget to Check For Return of Conscious Levels

You may read that for a patient with cerebral contusion, your physician documented that the patient fell unconscious and then returned to normal pre-existing levels of consciousness. In this case, you confirm the how long the unconsciousness lasted. If the loss of consciousness was prolonged, i.e. for more than 24 hours, you report ICD-9 code 851.04 (Cortex [cerebral] contusion without open intracranial wound with prolonged [more than 24 hours] loss of consciousness and return to pre-existing conscious level). This corresponds to ICD-10 code S06.335A (Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter).

However, if your physician documents that the patient did not regain the pre-existing levels of consciousness, you report ICD-9 code 851.05 (Cortex [cerebral] contusion without open intracranial wound with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level) or ICD-10 code S06.336A (Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter). Remember, for ICD-10 code S06.336A, make sure your physician also documents that the patient survived.