Pediatric Coding Alert

Provide precise documentation and narrow it down to the right code.

When your pediatrician treats head injuries after a fall, sports injury, or another trauma, without or without evident open injuries, you’ll need to know how to report these accurately once ICD-10 goes into effect. Take the pain out of your coding choices with this overview of the codes you’ll use after Oct. 1, 2014.

For a headache that your patient develops after a closed injury to the skull, as in concussion, you report code 310.2 (Postconcussion syndrome). This code in ICD-10 will map to F07.81 (Postconcussional syndrome). This type of headache can persist for weeks or months after a traumatic head injury.

In ICD-9 there is only one code that specifies ‘headache’, 784.0 (Headache). However, ICD-10 goes a step further to differentiate headache and the vascular headache that hasn’t been classified. So there are two codes you can look for: G44.1 (Vascular headache, not elsewhere classified) and R51 (Headache). Therefore, you will need to differentiate between the two before selecting a code.

Coding for the late effect of an intracranial injury is more descriptive in ICD-10 as it specifies the loss of consciousness and also confirms the same to be of unspecified duration.

In ICD-9, code 907.0 (Late effect of intracranial injury without skull fracture) describes headache that develops as a late effect of an intracranial injury without any fracture in the skull. The ICD-10, the code S06.9X9S (Unspecified intracranial injury with loss of consciousness of unspecified duration,) clearly defines that there is a loss of consciousness of an unspecified duration after the intracranial injury.

When the physician just documents ‘head injury’ or ‘minor head injury’ and does not mention anything else, you turn to ICD-9 code 959.01 (Other and unspecified injury to head). Most of the time, your pediatrician may not even request a CT scan or other extensive investigations. Remember that this code excludes concussion. This code maps to five codes in ICD-10 -- S09.8XXA (Other specified injuries of head, initial encounter), S09.90XA (Unspecified injury of head, initial encounter), S09.10XA (Unspecified injury of muscle and tendon of head, initial encounter), S09.11XA (Strain of muscle and tendon of head, initial encounter), and S09.19XA (Other specified injury of muscle and tendon of head, initial encounter).

And Don’t Forget These Pain Codes

Finally, check out pain codes 338.11 (Acute pain due to trauma) and G89.11 (Acute pain due to trauma) for acute pain in ICD-9 and ICD-10, respectively. Similarly for chronic pain due to trauma, you report 338.21 (Chronic pain due to trauma) in ICD-9 and code G89.21 (Chronic pain due to trauma) in ICD-10.