Revenue Cycle Insider

There are a few important questions to consider when coding for this condition.

Concussions are a very common reason patients seek medical care in primary care offices. From car accidents to injuries while playing sports, a concussion can occur unexpectedly to anyone. Because of the commonality of concussions, it’s important you know how to code them correctly.

Let’s dive deeper into the correct coding procedures for concussions with a case study.

Code This Concussion Case Study

A patient presents to their primary care practitioner after hitting a tree stump with their three-wheeler, falling off and striking their head on the ground. They arrive complaining of dizziness and having difficulty focusing on tasks. The patient reports losing consciousness for roughly three minutes. The provider examines the patient and sees no scratches, marks, or defects to their face or head and decides they should be observed for signs of a concussion. They document straightforward medical decision making (MDM). A total of 28 minutes are spent in the office with the patient.

The patient is then admitted to observation care, where the same provider spends another 47 minutes evaluating the patient over the course of several hours and ultimately diagnoses them with a concussion.

Choose the Correct E/M Codes

So, first report the correct evaluation and management (E/M) code from the following:

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.)
• 99213 (… low level of medical decision making … 20 minutes must be met or exceeded.)
• 99214 (… moderate level of medical decision making … 30 minutes must be met or exceeded.)
• 99215 (… high level of medical decision making … 40 minutes must be met or exceeded.)

Code 99212 reflects the primary care visit with straightforward MDM most appropriately in this case.

You will add code 99221 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded) for the observation care, and you’ll include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) so the payer is aware this service is separately payable from the office visit.

Medicare coding note: According to the Centers for Medicare & Medicaid Services (CMS) guidelines, you must add both the E/M visit and hospital services together and choose just one observation code that reflects the combined/total time. In this case, the physician spent a total time of 75 minutes on the patient’s care, justifying 99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded).

Choose the Correct ICD-10-CM Codes

To narrow down your diagnosis code choices, you’ll need to know two pieces of information first: Did the patient lose consciousness when the concussion occurred? If so, for how long did the patient lose consciousness?

With this information, you’ll be able to narrow down your concussion diagnosis code choices to:

• S06.0X0- (Concussion without loss of consciousness)
• S06.0X1- (Concussion with loss of consciousness of 30 minutes or less)
• S06.0X9- (Concussion with loss of consciousness of unspecified duration)
• S06.0XA- (Concussion with loss of consciousness status unknown)

Based on the encounter specifics, ICD-10-CM code S06.0X1 (Concussion with loss of consciousness of 30 minutes or less, initial encounter) would be most appropriate for the patient’s encounter.

Make note: You’ll also need a 7^th character for the concussion diagnosis code. Choose one of the following 7^th characters, depending on encounter specifics:

• A = initial encounter
• D = subsequent encounter
• S = sequela.

Because this is the patient’s first encounter for this injury, be sure to include the 7^th character “A” on each of the ICD-10-CM codes.

To accurately convey to the payer how the patient was injured, it’s important to choose the correct external cause code. For this encounter, you would select V37.0XXA (Driver of three-wheeled motor vehicle injured in collision with fixed or stationary object). You would again need to add an “A” to show this was the patient’s initial encounter and to code to the 7^th character.

Bring the Claim Together

When you are ready to submit your claim, it should look like this:

• 99212
• 99221-25
• S06.0X1A
• V37.0XXA.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC