Neurosurgery Coding Alert

Knowing diffuse, focal TBI definitions critical.

Patients reporting to the surgeon with symptoms of traumatic brain injury (TBI) will need immediate intervention to gauge the severity of the injury and what treatment the patient might need.

Coding departments in neurosurgery practices will need to use their skills to make sure the patient is diagnosed correctly; this will help ensure proper care for the patient for the injury (and beyond). They’ll also need to find out whether or not the patient actually suffered a TBI, and how severe the injury was.

Read on for more information regarding the diagnosis and treatment of TBI.

Check Out These Serious TBI Symptoms

When a patient has a potential TBI, the symptoms could be mild and temporary in the best cases; in the worse cases, however, TBI can result in permanent disability or even death. Common symptoms of TBI may include confusion, memory problems, headaches, dizziness, mood changes, and difficulty concentrating.

The path to a TBI diagnosis often begins with an office/outpatient evaluation and management (E/M) service, which you’d code with 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.). Be observant, though; the physician might perform another E/M service — such as hospital inpatient or observation — as the first evaluation and management service. This is especially true in the case of TBIs, as they are often the result of accidents, assaults, and other serious incidents.

The provider will likely perform the E/M in tandem with a brain imaging study; this will take the form of either a computed tomography (CT) or more typically magnetic resonance imaging (MRI).

For brain CTs, choose from one of the following codes:

• 70450 (Computed tomography, head or brain; without contrast material)
• 70460 (… with contrast material(s))
• 70470 (… without contrast material, followed by contrast material(s) and further sections)

For brain MRIs, you’ll choose a code from the 70551 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material) through 70559 (Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material(s), followed by contrast material(s) and further sequences) range.

Use S06.2X- for Diffuse TBI

There are two types of TBI for coding purposes. The first we’ll address is diffuse TBI, which is a brain injury that affects multiple spots in the brain, not just a single focal point. Diffuse TBI often occurs when the patient’s brain sustains a rapid acceleration/deceleration, often due to blunt force trauma or sudden impact to the head. Diffuse TBI can lead to widespread brain damage that could affect patient functions such as cognition, memory, motor skills, and emotional regulation.

Choose a code from the S06.2X- (Diffuse traumatic brain injury) code set for diffuse TBI. When reporting a diagnosis code for diffuse TBI, you must account for whether the patient lost consciousness along with the duration of the patient’s loss of consciousness (if it occurred) with the 6th character — or their death, depending on the situation. The 5th character in these diagnoses is always “X.” Codes for diffuse TBI are:

• S06.2X0- (Diffuse traumatic brain injury without loss of consciousness)
• S06.2X1- (Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less)
• S06.2X2- (Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes)
• S06.2X3- (Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes)
• S06.2X4- (Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours)
• S06.2X5- (Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious levels)
• S06.2X6- (Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving)
• S06.2X7- (Diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness)
• S06.2X8- (Diffuse traumatic brain injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness)
• S06.2XA- (Diffuse traumatic brain injury with loss of consciousness status unknown)
• S06.2X9- (Diffuse traumatic brain injury with loss of consciousness of unspecified duration)

Use S06.30- for Focal TBI

The second type of TBI is focal TBI, which is a brain injury that affects a specific, localized area of the brain rather than multiple regions (diffuse). Focal TBIs often happen when there is direct impact or force applied to a specific part of the head, which can lead to damage in that specific area of the brain.

There are numerous potential causes for focal TBIs: falls, vehicle accidents, sports injuries, assaults, or penetrating injuries such as gunshot wounds or sharp objects penetrating the skull. Depending on the location of the TBI and the damage suffered, the severity and symptoms of focal TBI can also vary.

Choose a code from the S06.30- (Unspecified focal traumatic brain injury) code set for focal TBI. Much like diffuse TBI, when reporting a diagnosis code for focal TBI, you must account for the patient’s loss of consciousness (if any) and duration with the 6th character — or their death, depending on the situation.

Unlike diffuse TBI, the 5th character in these diagnoses is always “0” to account for the TBI’s unspecified status.

Remember 7^th Character, Code Also Notes

All diffuse TBI patients — diffuse and focal — also require a 7th character to complete their diagnoses. You’ll choose from the following 7th character on all diffuse TBI patients:

• A = initial encounter
• D = subsequent encounter
• S = sequela

In the notes under the headings for S06.2- and S06.3-, ICD-10 reminds you to use an additional code, if applicable, for traumatic brain compression or herniation. If the patient suffers from either of these injuries as well as the TBI, choose one of the following codes:

• S06.A0- (Traumatic brain compression without herniation)
• S06.A1- (Traumatic brain compression with herniation).