Pain Management Coding Alert

Question: Our physician recently performed an evaluation and management (E/M) service for a new patient with a confirmed diagnosis of traumatic brain injury (TBI). Notes indicate that the physician performed a comprehensive history and examination, along with moderate-complexity medical decision making (MDM). What is the correct coding for this encounter?

Kentucky Subscriber

Answer: On the claim, you’ll report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity …) for the E/M service.

As for the correct diagnosis code, you’re going to need more information. If the patient is suffering from a diffuse TBI, you’ll choose a code from the S06.2- (Diffuse traumatic brain injury) diagnosis code group.

Definition: According to brainandspinalcord.org, diffuse TBIs occur over a more widespread area of the head, and not in one specific location. “Diffuse [TBI] isn’t the result of a blow to the head. Instead, it results from the brain moving back and forth in the skull as a result of acceleration or deceleration,” the website reports.

Patients with diffuse TBI might have recently suffered:

• an automobile accident;
• a sports-related accident;
• violence;
• a fall, or falls; or
• child abuse, such as shaken baby syndrome.

This is only one of the two TBI types, however. You patient might also be suffering from a focal TBI. If the patient is suffering from a focal TBI, you’ll choose a code from the S06.30 (Unspecified focal traumatic brain injury) diagnosis code group.

Definition: Unlike diffuse TBIs, focalinjuries are in one area of the brain. Focal TBIs could occur in patients that have suffered:

• a severe blow to the head;
• a violent assault; or 
• a gunshot wound to the head.

Choosing among the TBI ICD-10s can be a bit puzzling, as you’ll need to code to the seventh digit for most of the TBI diagnoses. The sixth digit indicates how long the patient lost consciousness due to the TBI, if at all, and patient status, if pertinent. The seventh digit marks the type of encounter the E/M. For the TBI codes that require a seventh character: 

• use A for initial encounter, 
• use D for subsequent encounter, and
• use S for sequela. 

So, let’s say encounter notes indicate that the patient’s lost consciousness for 3 hours, 55 minutes as a result of a focal TBI. This is the initial encounter for your physician with this patient, even though she has already been diagnosed with TBI. On the claim, you’d report S06.303A (Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter).