Accurate coding is an important function of neurologic practice. This section of CONTINUUM, contributed by members of the AAN Medical Economics and Management Committee, includes a table of helpful coding information related to the issue topic. The table may include diagnosis coding, Evaluation and Management (E/M) coding, procedure coding, or a combination, depending on which is most useful for the subject area of the issue.
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Codes Used in Traumatic Brain Injury
Acute Injury Codes
Note that codes in categories 800, 801, 803, 804, 851, 852, 853, and 854 require a fifth digit as follows:
0 unspecified state of consciousness
1 with no loss of consciousness
2 with brief [less than 1 hour] loss of consciousness
3 with moderate [124 hours] loss of consciousness
4 with prolonged [more than 24 hours] loss of consciousness and return to preexisting conscious level
5 with prolonged [more than 24 hours] loss of consciousness without return to preexisting conscious level
Use fifth-digit 5 to designate when a patient is unconscious and dies before regaining consciousness, regardless of the duration of loss of consciousness
6 with loss of consciousness of unspecified duration
7 with concussion, unspecified
Coding manifestation is encouraged since there is not one common presentation for traumatic brain injury (TBI). The "coma" codes from 780.0 to 780.93 may not be used with TBI. Likewise, memory loss, 780.93, may not be used with TBI. The manifestation codes should be listed after the primary TBI code from the preceding list during the acute hospitalization.
Following is a list of relatively new or little known TBI code manifestations:
These codes are new and available for use beginning October 1, 2010.
The 799-series codes (different from those mentioned above) allow providers to code emotional/behavioral symptoms without using mental health diagnosis codes. These codes do not replace mental health diagnosis codes. Providers should use these codes when they observe the symptoms but a mental health diagnosis is not established. While these codes are intended to be used for TBI symptoms, they are not limited to TBI.
Other manifestations, such as paresis, speech and language disturbances, and sleep disorders, may be found in the ICD-9-CM index and are too numerous to list here.
Late Effects of Traumatic Brain Injury
Anytime after the acute phase, manifestations of TBI would be considered "late effects." The first-listed code becomes the manifestation (late effect), and the second code is a "late effect code" appropriate to the injury as listed below:
Screening for Traumatic Brain Injury
Especially in the military setting, patients may be screened for possible TBI. The code to be used in this situation is
Personal History of Traumatic Brain Injury
It may be of value in some cases to add the information to a list of diagnoses that a patient has a history of TBI, and instances may occur when no "late effect" is present; this information needs to be captured. In that case, use the code
This code may not be a first-listed diagnosis.
CURRENT PROCEDURAL TERMINOLOGY CODING FOR TRAUMATIC BRAIN INJURY
Current Procedural Terminology (CPT) coding does not depend on the diagnosis. It depends on the work performed in the service, and more work is needed for more serious presenting problems.
New patients with moderate to severe TBI are usually level 5 consultations CPT 99255 or level 3 admissions CPT 99223 because of the altered mental state and risk of substantial morbidity.
When managing the patient in the intensive care unit, and when the patient is unstable and critically ill, the correct codes are the critical care codes. These codes, CPT 99291 and 99292, use time as the basis for setting level of service instead of bullet points.
New office patients often have concussion, and the level of Evaluation and Management (E/M) service depends on the severity of the presenting problem and risk. For example, a level 3 office new patient visit CPT 99203 would be a high school athlete presenting asymptomatic 4 days after a concussion, requesting permission to return to playing on the football team next week. Symptomatic TBI patients usually require a higher level of service when seen in the office.
The template at the end of this article is a useful reminder of all the particular elements that must be documented in each new, consultation, or admission note. The breakdown of bullets required for each kind of follow-up service is beyond the scope of this summary.
Tara A. Cozzarelli, RN, LCDR, USPHS; Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, reviewed and made suggestions for this coding table.© 2010 American Academy of Neurology