jhorner1962
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Hello I am new to this forum and I am a Coding Educator with a coding question.
We have providers who like to use the 'post-Concussion' syndrome diagnosis code F07.81 for many issues. I am looking and reading literature and it is a bit confusing.
About the patient, his final diagnosis is post-concussion with profound cognitive impairment (MOCA 11/30) but I am not sure MD documentation supports it. His documentation does not mention any head injury but he was in a MVA 4 months ago. So the main complaint is confusion and worsening memory loss. I don't see any mention of headache, dizziness or the typical 3+ symptoms you would see with PCS. He does state some worsening hearing loss but doesn't tie that to MVA.
We did discuss this further with the provider (Neurologist) and he explained he didn't have to hit his head to have a head injury. The provider went back in and added S09.90XS which I also don't agree with since he didn't mention a head injury. So my question is 'do we code with F code on its own, with the undocumented Head injury, or cognitive impairment/memory loss.
Can also use some additional educational materials if anyone know where I find them.
Thank you Joan Horner
We have providers who like to use the 'post-Concussion' syndrome diagnosis code F07.81 for many issues. I am looking and reading literature and it is a bit confusing.
About the patient, his final diagnosis is post-concussion with profound cognitive impairment (MOCA 11/30) but I am not sure MD documentation supports it. His documentation does not mention any head injury but he was in a MVA 4 months ago. So the main complaint is confusion and worsening memory loss. I don't see any mention of headache, dizziness or the typical 3+ symptoms you would see with PCS. He does state some worsening hearing loss but doesn't tie that to MVA.
We did discuss this further with the provider (Neurologist) and he explained he didn't have to hit his head to have a head injury. The provider went back in and added S09.90XS which I also don't agree with since he didn't mention a head injury. So my question is 'do we code with F code on its own, with the undocumented Head injury, or cognitive impairment/memory loss.
Can also use some additional educational materials if anyone know where I find them.
Thank you Joan Horner