Pain Management Coding Alert

Question: The PM specialist diagnoses a patient with a concussion. What is the best ICD-10 code for this encounter?

West Virginia Subscriber

Answer: You'll likely want to find more information, if at all possible, about the patient's condition before choosing a concussion code. Here are the basics of concussion coding, which you can use to bolster your knowledge after getting more details about the patient's specific concussion:

The ICD-10 codes for concussion are, on the surface, easy to assign based on the patient's history. You would choose S06.0X- (Concussion), adding a sixth digit, 0, if the patient did not lose consciousness during the incident; 1 if there was a loss of consciousness that was less than 30 minutes; or 9 if a loss of consciousness of an unspecified duration occurred.

The code, however, takes a seventh digit that can muddy the waters for coders. If this is the patient's first encounter for the condition, you would add the seventh digit, A, for the initial encounter. But if the patient is seen again in a week and now has no further symptoms of the concussion, the seventh digit will be a D for subsequent visit because the patient is now in the healing phase and no longer under treatment.

Also: For concussion patients, add a code from chapter 20 to describe how the concussion happened. So, if a patient is seen initially for a concussion from a playground slide accident, you could use W09.0XXA (Fall on or from playground slide, initial encounter); if a patient is seen initially for a concussion he suffered during a football practice, you'd use W21.81XA (Striking against or struck by football helmet, initial encounter) and Y92.321 (Football field as the place of occurrence of the external cause) to round out your reporting.  

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