Psychiatry Coding & Reimbursement Alert

Don’t forget: Use additional code to report post-traumatic headache, if present.

When reporting a diagnosis of postconcussion syndrome using the ICD-10 coding system, you’ll be relieved to know that you do not have to deviate much from the way in which you report this diagnosis using ICD-9 codes – the descriptors of the diagnosis codes and the list of inclusions and exclusions are very similar between the two systems of codes.

ICD-9: When your psychiatrist arrives at a diagnosis of postconcussion syndrome, you’ll have to report 310.2 (Postconcussion syndrome) if you are using ICD-9 codes. You’ll use the same diagnosis code if your clinician’s diagnosis is also postcontusion syndrome or encephalopathy; posttraumatic brain syndrome, nonpsychotic; or status postcommotiocerebri. A parenthetical note with this code advises to “Use additional code to identify associated post-traumatic headache, if applicable (339.20-339.22).”

But, you cannot use 310.2 if your clinician diagnoses any organic psychotic conditions following head injury (293.0-294.0); frontal lobe syndrome (310.0); or postencephalitic syndrome (310.89).

ICD-10: When you begin using ICD-10 codes, the ICD-9 code 310.2 that you use to report a diagnosis of postconcussion syndrome will crosswalk to F07.81 (Postconcussional syndrome). The list of inclusions and exclusions are similar to what you will find in the list of inclusions and exclusions for 310.2.

You also report F07.81 if the diagnosis of your clinician is postcontusional syndrome (encephalopathy) or post-traumatic brain syndrome, nonpsychotic. As in ICD-9, you will have to use an additional code to identify any associated post-traumatic headache (G44.3-).You cannot use F07.81 for a diagnosis of postencephalitic syndrome (F07.89) or current concussion (brain) (S06.0-).

Finally, note that under F07, ICD-10 advises you to code first the underlying physiological condition, which would also apply to F07.81.

Check These Basics Briefly

Documentation spotlight: Your psychiatrist will arrive at a diagnosis of postconcussion syndrome based on a complete history and a complete evaluation of the patient. Your psychiatrist will perform a complete mental status examination, a complete psychiatric and medical history of the patient and family, and a review of systems; he or she will also order and interpret diagnostic tests, neurobehavioral tests, and other evaluation questionnaires.

Some of the findings that your clinician would most likely record in a patient with postconcussion syndrome will include headache, dizziness, problems with sleep, irritability, attention and concentration deficits, seizures, depression, anxiety, fatigue, reduced memory, suicidal or homicidal tendencies, speech impairment, and disorientation.

Tests: If your clinician suspects a diagnosis of postconcussion syndrome based on history and signs and symptoms, your psychiatrist will want to order some imaging studies such as a CT or an MRI to further confirm the diagnosis and to check for complications. He might also perform an EEG to help detect seizures and other abnormalities.

Apart from these tests, your psychiatrist might also order for some lab tests as well as subject the patient to some neurobehavioral testing, such as the Neurobehavioral Rating Scale or Ranchos Los Amigos Cognitive Scale, to assess cognitive deficits and to assess the severity of the condition.

The care planning will include assessment of complications that may need treatment through hospitalization, psychological support, cognitive and behavioral psychotherapy, and family therapy to help the family cope with issues regarding the patient and to help them in managing the condition better so that the patient will benefit.

Example: Your psychiatrist recently reviewed a 45-year-old male patient who was joined by his wife. She complained that ever since her husband had a car accident about three months prior, he had become very withdrawn and irritable. She said that he often spent hours staring at nothing and would appear very listless. The patient also suffered from problems with sleep and would often suffer from memory deficits. She also said that he suffered from headache from time to time;it was initially very uncontrollable, but she said that it was now more easily tractable.

Upon examination, your psychiatrist notes that the patient is well groomed and doesn’t seem to be suffering from any signs of depression or anxiety. Your clinician also notes that the patient doesn’t seem to be well-oriented to place and time, has memory and speech deficits, and seems to be slow in comprehending what he is being told. Your clinician also notes that the patient does not seem to be suffering from any kind of suicidal or homicidal tendencies.

Although his wife says her husband has not had any seizures following the accident, your clinician asks for an EEG to check if there are any abnormalities that may point to the risk of the patient developing seizures in the future.

He also subjects the patient to neurobehavioral tests, such as the Neurobehavioral rating scales and the Ranchos Los Amigos Cognitive Scale, to assess the patient’s cognitive deficits and to check for recovery following the head injury.

Your psychiatrist also orders for a CT scan to assess the patient’s condition and to check if there are any other complications that might be affecting his recovery.

Based on history, signs and symptoms, observations made during physical and mental status examination, and interpretations of neurobehavioral tests and other diagnostic tests, your clinician is able to confirm a diagnosis of postconcussional syndrome along with chronic headache.

What to report: You will report the initial diagnostic evaluation that the psychiatrist provided with 90792 (Psychiatric diagnostic evaluation with medical services). You report the diagnosis with 310.2 if you are using ICD-9 codes. You report the headache the patient is suffering from with the ICD-9 code, 339.22 (Chronic post-traumatic headache). You report F07.81 and G44.329 (Chronic post-traumatic headache, not intractable) if you’re using ICD-10 codes to report the postconcussional syndrome and the headache that the patient is experiencing.