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Retained bullet in head?

  1. #1
    Default Retained bullet in head?
    Medical Coding Books
    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?
    Heidi Thompson, CPC

  2. Default
    Maybe a Late effects code?
    Rachell Lindley, CPC
    Multispecialty Clinic Coding
    Audiology
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    OBGYN

  3. #3
    Default
    Like this?

    907.0 Late effect of intracranial injury without mention of skull fracture

    Just might work?
    Heidi Thompson, CPC

  4. Default 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.

  5. #5
    Default
    Quote Originally Posted by jwertane View Post
    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?
    Heidi Thompson, CPC

  6. Default
    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.

  7. #7
    Default
    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.

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