Wiki Need dx for closed head wound

[LEE ANN]

Need dx for closed head wound. That is the only thing stated in the progress note. States pt fell and suffered closed head wound. No mention of other conditions resulting from fall. The only thing I can find is 959.01 Head injury unspecified. Any suggestions...........

 

[RebeccaWoodward*]

This is what I use, also.

If the traumatic injury is documented as a closed head injury without further description, assign code 959.01

http://www.fortherecordmag.com/archives/ftr_060908p27.shtml