Neurosurgery Coding Alert

Question: What are the best diagnosis codes for an acute post-traumatic headache and a chronic post-traumatic headache? Most of the patients have had a head injury without an open fracture.

Missouri Subscriber

Answer: The ICD-9 manual includes several sections you-ll want to consider for the diagnoses, depending on the individual circumstances.
If your physician diagnoses a concussion, look at options such as 310.2 (Postconcussion syndrome) or V15.5 (Other personal history presenting hazards to health; injury) with 784.0 (Symptoms involving head and neck; headache). One of the late effects codes might work, due to the causal relationship. Consider reporting 905.0 (Late effect of fracture of skull and face bones), 906.0 (Late effect of open wound of head, neck, and trunk) or 907.0 (Late effect of intracranial injury without mention of skull fracture), based on your physician's documentation.
Finally, check out pain codes 338.11 (Acute pain due to trauma) and 338.21 (Chronic pain due to trauma). ICD-9 guidelines include a section on the compliant use of these new pain codes.
Bottom line: Ask for your physician's input on the best diagnoses for these cases, especially because of all the viable coding options.