Neurosurgery Coding Alert

Question: Encounter notes indicate that the neurosurgeon provided 62 minutes of critical care for a patient suffering from “focal TBI, LOC 23 min, w/blast injury of brain.” This was the initial encounter for this patient for this injury. How should I choose a diagnosis code for this note? It’s a little nebulous to me.

Delaware Subscriber

Answer: You should actually choose two diagnosis codes for this critical care encounter. First, the acronyms your surgeon used—TBI and LOC— translate to “traumatic brain injury” and “loss of consciousness,” respectively.

When you look at the focal TBI codes, you’ll see that S06.301A (Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, initial encounter) is the choice for this encounter.

Not done yet: In the instructions at the top of the S06.3- (Focal traumatic brain injury) code set, ICD-10 reports you should: “Use additional code, if applicable, for traumatic brain compression or herniation (S06.A-).”

To fully code this patient’s condition, head to the S06.A- (Traumatic brain compression and herniation) code set, where you’ll see that S06.8A1A (Primary blast injury of brain, not elsewhere classified with loss of consciousness of 30 minutes or less, initial encounter) is the correct diagnosis code.

Recap: On your claim, report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) with S06.301A and S06.8A1A appended.