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Dx code - Closed head injury

  1. Default Dx code - Closed head injury
    Medical Coding Books
    Can someone help me with a dx code for the following situation:
    Dx written on encounter form are as follows:
    Closed head injury(injury happened a number of years ago)
    Quadraplegia
    Seizure disorder
    Mood disturbance.

    I am having trouble putting a dx on the closed head injury and quadraplegia.

    Any help and suggestions are greatly appreciated.

    Thanks.

  2. #2
    Location
    Houston, Texas
    Posts
    24
    Wink More specific DX answer...
    Hi J,
    I would say 907.0- Late effects of intracranial injury w/o mention of skull fracture -OR-
    905.0- Late effects of skull fracture, (not knowing the specifics); and then the 344.00 for quadraplegia and 345.0 for the siezure disorder. Code 296.90- episodic mood disturbance or 396.99 for mood disorder NEC last. Never code a mood disorder in the top three dx's if you can help it unless you are a mental health facility. If you know the cause of the head injury, (i.e., mva), you can append the correct E code at the end of the list.

  3. #3
    Location
    Columbia, MO
    Posts
    12,531
    Default
    This is from the guidelines for ICD-9 coding:
    Late Effects
    A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second.
    An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded (at the fourth and fifth-digit levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Location
    Columbia, MO
    Posts
    12,531
    Default
    This is from the guidelines for ICD-9 coding:
    Late Effects
    A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second.
    An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded (at the fourth and fifth-digit levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    For quadriplegia- 344 .89 Other specified paralytic syndrome could fit in if you analyse the description in the note under344.

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