Remember External Cause Code With Concussion Dx
Question: A patient reports to the neurosurgeon with symptoms of headache, dizziness, and difficulty concentrating. The patient says that they fell off their bicycle and hit their head on the ground three days ago, and lost consciousness briefly — “for about two minutes,” according to the patient. They report that the symptoms have gotten worse since the day of the accident. Final diagnosis was concussion with loss of consciousness of less than 30 minutes. It is the first encounter with this patient for this injury. What is the correct ICD-10-CM coding for this encounter? Revenue Cycle Insider Subscriber Answer: You should report a pair of codes for this patient: one ICD-10-CM code for the concussion and one external cause ICD-10-CM code to explain how the injury occurred. So, first report S06.0X1A (Concussion with loss of consciousness of 30 minutes or less, initial encounter) for the patient’s concussion. Then, report V18.0XXA (Pedal cycle driver injured in noncollision transport accident in nontraffic accident, initial encounter) to represent the cause of the patient’s injury. Remember to include 7th character “A” on each of the ICD-10-CM codes to indicate that this was an initial encounter for this patient for this injury. The S06.- (Intracranial injury) subcategory requires a 7th character to show whether the encounter for this injury was initial (“A”), subsequent (“D”), or sequela (“S”). Also, don’t code for the presenting symptoms of headache, dizziness, and difficulty concentrating. These are all symptoms of a concussion, and you shouldn’t report them if the physician reaches a concussion diagnosis. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
