Need Help Concussion Coding

[nskripsky]

Need some guidance on concussion coding, patient comes in with concussion without loss of consciousness still having problems with headaches and fatigue referred by family physician, our provider coded S06.0X0S, I don't agree I think it needs to be coded F07.81 then S06.0X0A initial encounter our first time seeing then Y93.72 patient is a high school wrestler. I believe that the S code should not be used as a primary code in this case. Need some quidance on the S code if it should be used as a primary diagnosis and if the Y code needs to be added. Injury happened in December 2015.

Hopefully someone can shed some light on concussion codes.

 

[Cynthia Hughes]

Concussion Coding

Need some guidance on concussion coding, patient comes in with concussion without loss of consciousness still having problems with headaches and fatigue referred by family physician, our provider coded S06.0X0S, I don't agree I think it needs to be coded F07.81 then S06.0X0A initial encounter our first time seeing then Y93.72 patient is a high school wrestler. I believe that the S code should not be used as a primary code in this case. Need some quidance on the S code if it should be used as a primary diagnosis and if the Y code needs to be added. Injury happened in December 2015.

Hopefully someone can shed some light on concussion codes.

I disagree with reporting F07.81 as the physician did not diagnose post-concussion syndrome which is a clinical judgment and diagnosed based on specific criteria including the presence of 3 symptoms from a list of commonly associated symptoms. So, if you have active problems of headaches and fatigue that the physician has diagnosed as late effects of the concussion, then codes for the nature of the sequela (post-traumatic headaches [see G44.3-], fatigue) would be listed first followed by the appropriate code for the sequela of concussion. Though this is the physician's first encounter with the patient, it is not for active management of the concussion but for evaluation and management of the late effects (sequela). An activity code is assigned only at the initial encounter for treatment of the injury. I hope this is helpful.

 

[mitchellde]

Yes I too disagree with the F07.81 unless the provider specifically documented this condition. The category description must apply for the full code description. F07 description is:
F07 Personality and behavioral disorders due to known physiological condition
According to what is posted this was not documented.
In addition, just because this is your provider's first encounter with the patient dies not make this the initial encounter for the patient. Keep in mind these are patient diagnosis codes, not provider encounter codes.
Normally sequela from injury requires a minimum of two codes, one for the presenting problem and one for the injury with he S 7th character. In most instances the present problem is sequenced first-listed, poisoning is an exception. And as indicated the activity codes are generally used only with initial encounter.

 

[nskripsky]

Thank you for your help.