Retained bullet in head?

[hthompson]

Is there a diagnosis code for this? It's been there since 1985! Apparently it's causing chronic headaches. I've got the codes for those dx, but do I just change the chronic pain code to caused by trauma?

 

[rachell1976]

Maybe a Late effects code?

 

[hthompson]

Like this?

907.0 Late effect of intracranial injury without mention of skull fracture

Just might work?

 

[jwertane]

Jeanne Wertanen, CPC

I think that I would code this as a 784.0 headache and then add to this code 729.6 Residual foreign body in soft tissue, and lastly 907.0 Late effect of intracranial injury without skull fracture. I would be hesitant to put a chronic pain code on the encounter.

 

[hthompson]

I think that I would code this as a 784.0 headache and then add to this code 729.6 Residual foreign body in soft tissue, and lastly 907.0 Late effect of intracranial injury without skull fracture. I would be hesitant to put a chronic pain code on the encounter.

On the Superbill, the dr marked:

Chronic Pain due to trauma
Retained bullet in head
Headache

I know I wasn't as clear before, but can you explain why you would be hesitant to put a chronic pain code on this encounter?

 

[cowansf]

If the foreign body is in the brain, I don't think that residual foreign body in soft tissue would be correct. However, I do think that a late effect code is the way to go.

 

[whaleheadking]

I think late effects of intracranial injury is good (though the bullet probably caused a fracture at the time), followed by headache.

I don't know if you need to include the bullet if you're not specifically treating it though. If you want to add the supplemental information, why not V48.6, disfigurements of head? This falls under "persons with a condition influencing thier health status." That's certainly true.