Neurosurgery Coding Alert

Don't assume just any closed injury is a contusion.

If your surgeon notes a nonspecific diagnosis like head injury, minor head injury, or closed head injury, you'll be left without sufficient info to nail the right code when ICD-10 is effective. That's because in ICD-10, you'll have more specific options to report minor bruises of the head and neck and other minor injuries with no loss of consciousness.

Currently you report the bruises on the scalp, face, or neck with ICD-9 code 920 (Contusion of face scalp and neck except eye[s]). A bruise is a minor injury in which there is internal bleeding without damage to the overlying skin. There isn't a cut and the skin remains intact. Code 920 includes bruise or hematoma without fracture or open wound and is inclusive of all contusions on the scalp, face, and neck. Hence, you report ICD-9 code 920 for any contusions of the cheek, ear (auricle), gum, lip, mandibular joint area, nose, and throat.

In ICD-10, you will need your surgeon to precisely identify and document the site of the contusion. For face contusions, you have specific codes for the right and left ear, nose, and oral cavity. Similarly, you have different codes for the contusions of the throat and other parts of the neck.

For the contusion of scalp and nose, you have codes S00.03XA (Contusion of scalp, initial encounter) and S00.33XA (Contusion of nose, initial encounter), respectively. You will be specific for the right and left side when reporting a contusion of ear. You will choose from codes S00.431A (Contusion of right ear, initial encounter) or S00.432A (Contusion of left ear, initial encounter) depending upon whether the right or left ear was involved. If your surgeon does not document the side, you report S00.439A (Contusion of unspecified ear, initial encounter). Depending upon the location of the contusion, other options for you include S00.531A (Contusion of lip, initial encounter), S00.532A (Contusion of oral cavity, initial encounter), S00.83XA (Contusion of other part of head, initial encounter), S10.0XXA (Contusion of throat, initial encounter), S10.83XA (Contusion of other specified part of neck, initial encounter).

Assign Specific Codes for Unspecified Parts of Head, Neck

You can falter in a situation where in your surgeon does not specifically mention which part of the head or the neck had the contusion. In this case, you will report S00.93XA (Contusion of unspecified part of head, initial encounter) for the contusion of the head and S10.93XA (Contusion of unspecified part of neck, initial encounter) for the contusion of the neck.

Check for Exclusions

Make sure you know what you never report with ICD-9 code 920. The ICD-9 code 920 enlists some exclusions. These include concussion, hemarthrosis, and internal organ injuries that incidental to crushing injury, dislocation, fracture, internal injury, intracranial injury, nerve injury, and open wound.

Select the Right Code for Head Injury

When your surgeon just documents 'head injury' or 'minor head injury' and does not mention anything else, you turn to ICD-9 code 959.01 (Other and unspecified injury to head). Most of the time, your surgeon may not even request a CT scan or other extensive investigations. Remember that this code excludes concussion and head injury with loss of consciousness. This code maps to five codes in ICD-10 -- S09.8XXA (Other specified injuries of head, initial encounter), S09.90XA (Unspecified injury of head, initial encounter), S09.10XA (Unspecified injury of muscle and tendon of head, initial encounter), S09.11XA (Strain of muscle and tendon of head, initial encounter), and S09.19XA (Other specified injury of muscle and tendon of head, initial encounter).

Confirm Extent of Injury in Closed Head Injury

Another term you will frequently encounter as a clinical diagnosis in clinical notes is 'closed head injury.' This diagnosis may not necessarily mean a contusion as the term 'closed' has been used. Your surgeon will generally use this diagnosis to record a head injury more extensive than a contusion but not as extensive to qualify as major intracranial injury. A concussion would represent the beginning of the spectrum of intracranial injuries.

In this case, you will turn to the series 850.0 (Concussion with no loss of consciousness) " 854.1 (Intracranial injury of other and unspecified nature with open intracranial wound). You may request your surgeon to specifically document the extent of injury and also check if your surgeon requested a CT scan to evaluate the extent of the injury. "These diagnosis codes require a description of the duration of lost consciousness, if it occurred," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Remember: If your surgeon records that the patient sustained a minor head injury and didn't have loss of consciousness or other significant brain or skull injuries, you can turn to code 959.01.