Neurosurgery Coding Alert

Ask your surgeon for precise documentation and narrow down to the right code.

When your surgeon treats headaches after a fall, another trauma, without or without evident open injuries, or after fracture(s) in the skull, you'll need to know how to report these accurately. Take the pain out of your headache choices with this overview of the codes you'll use hen ICD-10 is implemented.

For a headache that your patient develops after a closed injury to the skull, as in concussion, you report code 310.2 (Postconcussion syndrome). This code in ICD-10 will map to F07.81 (Postconcussional syndrome)

"This type of headache can persist for weeks or months after a traumatic head injury," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

You may also report code V15.5 (Personal history of injury presenting hazards to health) if the patient is reported to develop headache after an injury.

In ICD-9 there is only one code that specifies 'headache', 784.0 (Headache). However, ICD-10 goes a step further to differentiate headache and the vascular headache that hasn't been classified. So there are two codes you can look for: G44.1 (Vascular headache, not elsewhere classified) and R51 (Headache).

Site Of Fracture Guides Your Choice Of Codes For Post-Traumatic Headache

You have a perplexing choice of codes to report in ICD-10 when your surgeon treats a patient who develops a headache as a late sequelae to the fracture of skull or facial bones. In ICD-9, you turn to code 905.0 (Late effect of fracture of skull and face bones). In ICD-10, you'll look at the following codes:

• S02.0XXS Fracture of vault of skull, sequela
• S02.10XS Unspecified fracture of base of skull, sequela
• S02.110S Type I occipital condyle fracture, sequela
• S02.111S Type II occipital condyle fracture, sequela
• S02.112S Type III occipital condyle fracture, sequela
• S02.113S Unspecified occipital condyle fracture, sequela
• S02.118S Other fracture of occiput, sequela
• S02.119S Unspecified fracture of occiput, sequela
• S02.19XS Other fracture of base of skull, sequela
• S02.2XXS Fracture of nasal bones, sequela
• S02.3XXS Fracture of orbital floor, sequela
• S02.400S Malar fracture unspecified, sequela
• S02.401S Maxillary fracture, unspecified, sequela
• S02.402S Zygomatic fracture, unspecified, sequela
• S02.411S LeFort I fracture, sequela
• S02.412S LeFort II fracture, sequela
• S02.413S LeFort III fracture, sequela

Overall, the codes are more specific in site and type of fracture(s), such as fractures in the skull vault, base, occiput, nasal bones, orbital floor, mandible, other specified and unspecified bones in the skull and face. "Part of the intent of ICD-10 is to provide greater specificity of diagnostic codes to facilitate outcomes research," says Przybylski.

Look for Wound Site for Headache After Open Wound

Whereas ICD-9 has only one code for you to report headache that occurs as a late effect of open wound in the head, neck, and trunk, in ICD-10, you have five codes mapping to the same. The ICD-9 code you report is 906.0 (Late effect of open wound of head, neck, and trunk). The choices you have in ICD-10 are as follows:

• S01.90XS Unspecified open wound of unspecified part of head, sequela
• S11.90XS Unspecified open wound of unspecified part of neck, sequela
• S21.90XS Unspecified open wound of unspecified part of thorax, sequela
• S31.000S Unspecified open wound of lower back and pelvis without penetration into retroperitoneum, sequela
• S31.109S Unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, sequela

These codes focus on the area of the body involved, i.e., the head, neck, thorax, back and pelvis, and the abdominal wall. Also note that all codes mention that the open wound is 'unspecified' and the part of the body area affected is also 'unspecified'. "Only the first two codes might be typically used in post-traumatic headache," says Przybylski.

Code for late effect of intracranial injury is more descriptive in ICD-10 as it specifies the loss of consciousness and also confirms the same to be of unspecified duration.

In ICD-9, code 907.0 (Late effect of intracranial injury without skull fracture) describes headache that develops as a late effect of an intracranial injury without any fracture in the skull. The ICD-10, the code S06.9X9S (Unspecified intracranial injury with loss of consciousness of unspecified duration, sequel) clearly defines that there is a loss of consciousness of an unspecified duration after the intracranial injury.

And Don't Forget These Pain Codes

Finally, check out pain codes 338.11 (Acute pain due to trauma) and G89.11 (Acute pain due to trauma) for acute pain in ICD-9 and ICD-10, respectively. Similarly for chronic pain due to trauma, you report 338.21 (Chronic pain due to trauma) in ICD-9 and code G89.21 (Chronic pain due to trauma) in ICD-10.

Editor's note: For the complete list of codes to which 905.0 maps to in ICD-10, please e mail the editor at tjandoo@codinginstitute.com.