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Wiki Concussion

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mcdream

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Hi all,
Seeking assistance with coding resolved condition verses active condition.
Patient treated in ED for concussion 2 weeks ago and now presents to PCP for headache assign code for current or history of?

Scenario 1- Resolved Condition
CC: Follow-up headache
Headache resolved prior to visit (resolved 3 days ago)
#Non-intractable headache
Assign R51.9- headache, unspecified or G44.309- post traumatic headache, unspecified, not intractable or Z87.898- history of other specified condition
#Concussion without loss of consciousness
Assign S06.0X0D- concussion without loss of consciousness, subsequent encounter or Z87.820- history of traumatic brain injury without residual condition

Scenario 2- Active Condition
CC: Follow-up headache
Headache since concussion 2 weeks ago
#Non-intractable headache
Assign R51.9- headache, unspecified or G44.309- post traumatic headache, unspecified, not intractable
#Concussion without loss of consciousness
Assign S06.0X0D- concussion without loss of consciousness, subsequent encounter or S06.0X0S- concussion without loss of consciousness, sequela

TIA
 
If the provider is documenting the direct relationship between the concussion and the headache, the I would personally code the 2nd scenario.
 
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