Neurosurgery Coding Alert

Question: Is it mandatory that loss of consciousness be documented for submitting diagnosis of concussion? Can you suggest how we can report for conscious patients with this condition using ICD-9 codes?

Codify Subscriber

Answer: A patient does not have to be unconscious to code a concussion—the diagnosis should be made based on the patient’s symptoms and not on whether or not he is awake. There are several different diagnosis codes that might be appropriate, depending on the type of head injury you treat.

If the patient has a contusion of the head, you would report ICD-9 code 920 (Contusion of face, scalp, and neck except eye[s]). Remember that a contusion, by definition, includes a bruising injury that does not break the skin. You should check for exclusions. The exclusion note for 920 refers to various other codes for more significant injuries that go beyond a basic bump on the head.

When the provider doesn’t document any further detail than “head injury,” you would use 959.01 (Other and unspecified injury to head). This code also has a list of exclusions similar to 920.

However, since Oct 2015, you have ICD-10 implemented. So you should consider reporting the ICD-10 codes.

ICD-10-CM codes: The code 920 maps to ICD-10 codes S00.03XA (Contusion of scalp, initial encounter) - S10.93XA (Contusion of unspecified part of neck, initial encounter). The code 959.01 maps to codes S09.8XXA (Other specified injuries of head, initial encounter) - S09.19XA (Other specified injury of muscle and tendon of head, initial encounter).

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. This series represents very serious injuries resulting from significant impacts to the head. Specifically, the 854 set includes cavernous sinus and intracranial injury.

The code 854.01 maps to ICD-10 code series S06.1X0A (Traumatic cerebral edema without loss of consciousness, initial encounter) - S06.9X0A (Unspecified intracranial injury without loss of consciousness, initial encounter).

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. 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 physician is seeing the patient, such as mild memory disturbance (310.8) or chronic post-traumatic headache (339.22).

In ICD-10, you have a definite choice of code S06.0X0S (Concussion without loss of consciousness, sequela) for concussion without loss of consciousness. The ICD-9 code 907.0 maps to codes S06.0X0S - S06.9X9S (Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela). The code 310.8 maps to two ICD-10 codes F07.89 (Other personality and behavioral disorders due to known physiological condition) and F48.2 (Pseudobulbar affect) and the code 339.22 maps to ICD-10 codes G44.329 (Chronic post-traumatic headache, not intractable) and G44.321 (Chronic post-traumatic headache, intractable).

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 cerebral contusion (851.4) cases, or it may occur months or years later, such as that due to a previous injury. In younger patients, this may be residual dizziness (780.4) or diplopia, also known as double vision (368.2) following a concussion.

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, Subacute delirium), followed by 907.0 (Late effect of intracranial injury without mention of skull fracture).

The code 851.4 now maps to ICD-10 codes S06.370A (Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, initial encounter) - S06.389A (Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, initial encounter). For dizziness, you submit ICD-10 code R42 (Dizziness and giddiness) and for diplopia, you submit ICD-10 code H53.2 (Diplopia).

Similarly, you have ICD-10 code F05 (Delirium due to known physiological condition) for subacute delirium.