Radiology Coding Alert

Question: What are the rules surrounding traumatic brain injury (TBI) coding? I can't figure out whether or not to code as diffuse TBI versus another form. Does the provider need to specify diffuse, or are there different symptoms/elements to look for in the patient's diagnoses to conclude diffuse TBI?

Washington Subscriber

Answer: This is a great question that can often be a source of frustration for some radiology, neurosurgery, and emergency room (ER) coders. There are no official, designated rules in place that coders may use as a guide to TBI coding. However, as long as coders use theICD-10-CM index properly, and avoid relying on any "outside" sources, they should have all the necessary tools at their disposal to reach an accurate diagnosis code.

In respect to "outside sources," this sort of diagnosis presents a perfect example as to why coders should not rely on a search engine, such as Google, to reach the correct ICD-10 code. If you search for "TBI + ICD-10" using Google, you are immediately greeted with S06.2X9D (Diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter). As you can imagine, this option is incorrect for numerous reasons.

Above all else, Google is making three fundamentally incorrect assumptions about this diagnosis code. First, there is no specification that the TBI is diffuse. Second, there is no documentation of loss of consciousness. And third, this diagnosis consists of a completely unfounded "subsequent encounter" seventh character. All in all, Google has completely failed you in respect to retrieving a remotely accurate diagnosis for TBI.

The correct diagnosis for "TBI," without any other specifications, is actually S06.9X0A (Unspecified intracranial injury without loss of consciousness, initial encounter). This can be found by either searching for TBI, Traumatic ⇒ brain injury; or Injury ⇒ brain (traumatic) within the ICD-10 index.

In order to reach a diffuse TBI diagnosis, there must be documentation of the term diffuse. Technically, a patient's initial presentation of TBI should be labeled as either diffuse or focal. Diffuse, simply put, pertains to numerous areas of the brain, while a focal TBI refers to a more localized event. However, it's common for a provider not to document as either, in which case you will opt for the unspecified code above. However, if the provider includes other symptoms or conditions alongside the TBI diagnosis, do not make the assumption that those warrant upcoding from TBI to diffuse or focal TBI.

If the additional diagnoses are not results of the TBI, they should be included separately, but do not use them to adjust or alter the primary diagnosis of TBI.