Wiki Shaken Baby Syndrome

blazeunreal

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We have a patient that is 21 years old, she has Cerebral Palsy, Epilepsy, and sever mental retardation. The cause of all of these things is Shaken baby syndrome and my doctor is insistent that we report the shaken baby syndrome code 995.55, however that code can only be report up to age 17. Is there a late effect or a personal history of code that would work in this case? I have looked and I am unable to find anything. before I go back to my Dr. and tell her I cannot bill this code I want to make sure I have no other options.
This is what her note says:

21 yo female with PMH significant for shaken baby syndrome with MR, hydrocephalus s/p vp shunt and epilepsy presents for initial evaluation and establishment for history of seizures. She is attended by her grandmother and aide.
Onset of seizures was 2 weeks old at the time she was diagnosed with shaken baby syndrome.

Thank you for your help!
 
Thank you, I was looking at that code and since it is a late effect classifiable to injury codes 850-854 would using 909.9 late effect of other and unspecified external causes be better? I do not see one that is classifiable to 995.55.
 
Since the 995.55 had to be reported with the acute injury code, I am assuming the original injury was in the 850-854 range. The patients current issue are all a result of the intracranial injury which was suffered as a result of the shaken baby. Correct? or am I going at this all wrong?
 
You are probably correct, The note has no mention of the original injuries. So I will go with what you suggested and present it to the Dr. hopefully she will agree. Thank you Again!
 
is the age specification really to age 17 for 995.55. i have a 19 year old that went to another mate in the army and knocked on door. the guy was drunk who answered the door and was hitting him. the doctor used 995.55 and changed decription in note to abusive head trauma,

our edit is to age 21 for code 995.55. do you have any docmentation

thanks

Gwen
 
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