A concussion is a type of traumatic brain injury caused by a blow, bump, or jolt to the head or by a hit to the body that results in rapid back and forth movement of the head and brain. Improve your diagnosis coding by recognizing the signs and symptoms.
Prevent Sports-Related Concussions
The Centers for Disease Control and Prevention (CDC), in the article “Responding to Concussion and Action Plan for Coaches,” highlights the main actions a coach needs to undertake in response to suspicion of a concussion. The HEADS UP Action Plan involves:
- Removing the player from play
- Seeking medical attention for the player
- Informing and educating parents
- Getting written concussion care instructions from the player’s physician
Identify a Concussion
The article “Signs and Symptoms of a Concussion” by Oregon Concussion Awareness and Management Program (OCAMP) categorizes signs of concussion, as seen by others, into three distinctive groups: physical, cognitive, and emotional signs.
- Physical signs of a concussion include clumsy movements, balance problems, physical weakness, and loss of consciousness.
- Physical symptoms of a concussion include headache, double or blurry vision, fatigue, dizziness, numbness, nausea, vomiting, and sensitivity to light or noise.
- Cognitive signs of a concussion include forgetfulness of events prior to and after the hit or fall, slow response to questions, and appearing confused or stunned.
- Cognitive symptoms of a concussion include a hazy feeling and problems with memory and concentration.
Emotional signs include change of mood, behavior, or personality. These signs are further backed by the symptoms the athlete reports. Players also experience emotional and sleep problems.
Improve Concussion Diagnostics
“Interassociation Consensus: Diagnosis and Management of Sport-Related Concussion Best Practices” by the National Collegiate Athletic Association (NCAA) highlights the diagnosis and management of sports-related concussions in all sports at the college level. The background section explains the different aspects of concussion injuries and the shortcomings in its diagnosis and management.
“The diagnosis and management of sport-related concussion is challenging for many reasons,” the NCAA states in the Best Practices. The NCAA and the Department of Defense partnered to develop the NCAA-DoD Grand Alliance, which comprises the Concussion Assessment, Research and Education Consortium (CARE) and the Mind Matters Challenge. CARE is on track to study more than 25,000 student-athletes and 1,000 concussions.
Code Concussion Care
One option for improving a healthcare provider’s ability to diagnose a concussion is the baseline test. The provider can perform a baseline test on the athlete pre-season to assess the athlete’s balance and brain function. The results can be used and compared to a similar exam conducted during the season if the athlete has a suspected concussion.
CPT® codes for psychological and neuropsychological testing, as of Jan. 1, 2019, are:
96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour
+96121 each additional hour (List separately in addition to code for primary procedure)
96132 Neuropsychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour
+96133 each additional hour (List separately in addition to code for primary procedure)
96136 Psychological or neuropsychological test administration and scoring by physician or other qualified health care professional, two or more tests, any method, first 30 minutes
+96137 each additional 30 minutes (List separately in addition to code for primary procedure)
96138 Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes
+96139 each additional 30 minutes (List separately in addition to code for primary procedure)
96146 Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only
Note: Values for these newer codes vary depending on who is doing the service (such as a psychologist or technician), and whether it is a base code or an add-on code.
ICD-10-PCS codes include:
GZ10ZZZ Psychological Tests, Developmental
GZ11ZZZ Psychological Tests, Personally and Behavioral
GZ12ZZZ Psychological Tests, Intellectual and Psychoeducational
GZ13ZZZ Psychological Tests, Neuropsychological
GZ14ZZZ Psychological Tests, Neurobehavioral and cognitive status
Some payers will accept a code from the Injuries to the Head (S00-S09) category, while others may require a code from the Mental, Behavioral and Neurodevelopmental Disorders (F01-F09) category.
About the author:
Shaqualya Mitchell-Sneed, MPA, CPC-P, CPMA, resides in Atlanta, Ga. and serves as Manager of Coding and Reimbursement of 30 spine and pain management clinics and five outpatient surgery centers in the Southeast. She has more than 13 years of experience in the medical industry focusing on operations and revenue. Mitchell-Sneed is a member of the Marietta, Ga., local chapter.