Eli's Rehab Report
No Specific Timing Exists Between Acute, Chronic
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Question: My physician documents "traumatic brain injury (TBI) with decreased activities of daily living (ADL) and difficulty walking, neurocognitive defects." Usually, I code the TBI after all of the rehab diagnosis, but should I code it as an acute code or a late effect? Do the same rules apply if the injury occurred one to three months ago? Virginia subscriber Answer: You first code the reasons for the patient's treatment at the rehab hospital. The reasons or symptoms comprise decreased ADL(780.99, Other general symptoms), difficulty walking (719.7), and neurocognitive deficits. Although physiatrists commonly refer to "neurocognitive deficits," no specific ICD-9 code links to this symptom specifically. However, possible alternatives include: Make sure to ask your provider which code fits with their use of the term "neurocognitive deficits." As for the TBI versus late effect, ICD-9 Coding Guidelines, Section I B.12, state, "There is no time limit on when a late effect can be used. The residual may be apparent early, such as in a cerebrovascular accident case, or it may occur months or years later, such as that due to a previous injury." This means that no specific timing of when a diagnosis transfers from the acute phase to the latent phase exists.
Therefore, you should follow what your physician documents or specifically indicates, because only he knows the patient's medical conditions.
However, make sure that your physician documents the difference in diagnosis between treatment in the acute phase versus treatment of sequelae from the illness or injury. For example, ask him, "Are you actively treating the traumatic brain injury, or are you treating the patient's residual condition(s) due to the traumatic brain injury?"
Eli's Rehab Report
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