Orthopedic Coding Alert

Question: We went to a seminar where they said to only report a concussion diagnosis code if the patient loses consciousness. We see a lot of student-athletes, so it’s common for our sports medicine physicians to diagnose head injuries. Which diagnosis should we report for conscious patients with this condition?
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Answer: A patient does not have to be unconscious to code a concussion—the diagnosis should be made based on the patient’s symptoms and not on whether or not he is awake. There are several different diagnosis codes that might be appropriate, depending on the type of head injury you treat.

If the patient has a contusion of the head, you should use 920 (Contusion of face, scalp, and neck except eye[s]), but remember that a contusion, by definition, includes a bruising injury that does not break the skin. You should check for exclusions in your ICD-9 book. The exclusion note for 920 refers to various other codes for more significant injuries that go beyond a basic bump on the head.

When the provider doesn’t document any further detail than “head injury,” you should use 959.01 (Other and unspecified injury to head). This code also has a list of exclusions similar to 920.

Significant injuries: You should report codes from the 850-854 series, including 854.01 (Intracranial injury of other and unspecified nature; without mention of open intracranial wound; with no loss of consciousness), for other specific and serious injuries involving the head. This series represents very serious injuries resulting from high-energy impacts to the head. Specifically, the 854 set includes cavernous sinus and intracranial injury.

If the patient had a brain injury more than a year ago, you should look to a late effects code. Using a late effects code creates the causality relationship between a prior injury and the current condition your provider is treating. A possible example is 907.0 (Late effect of intracranial injury without mention of skull fracture). In addition, you want to code as primary the actual residual condition for which the physician is seeing the patient, such as mild memory disturbance (310.8) or chronic post-traumatic headache (339.22).

What it is: A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has ended. There is no time limit on when you can use a late effect code. The residual may be apparent early, such as in cerebral contusion (851.4) cases, or it may occur months or years later, such as that due to a previous injury. In younger patients, this may be residual dizziness (780.4) or diplopia, also known as double vision (368.2) following a concussion.

Coding late effects generally requires two codes sequenced in the following order: first, the condition or nature of the late effect; and second, the late effect code. For instance, the condition code could be confusion (293.1, Subacute delirium ), followed by 907.0 (Late effect of intracranial injury without mention of skull fracture).