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Thread: History of concussion

  1. #1

    Default History of concussion

    AAPC: Back to School
    Hi all!
    Would V15.52 (hx of traumatic brain injury) or V15.59 (hx of injury) be better to use for a "history of concussions x 3". I'm not sure what qualifies as "traumatic".
    Last edited by SUEV; 04-28-2011 at 09:43 AM.
    Sue Vermette, CPC

  2. #2
    Join Date
    Apr 2007
    Boone, NC

    Default History of Concussions - Athlete

    I would love to know this as well. I have a professional athlete who has suffered from multiple concussions in the past playing football. I have 310.2 (Concussion syndrome), but would like to know if V15.52 or V15.59 would be the best choice.

  3. #3
    Join Date
    Apr 2007
    Austin, Texas


    Once a TBI diagnosis is entered into the insurance carrier system, then that diagnosis never goes away, even if the TBI was mild in nature without permanent damage. Your doctor needs to be as accurate as possible with these type diagnosis codes.

    http://www.mayoclinic.org/diseases-c...n/con-20032705 offers:
    "Post-concussion syndrome is a complex disorder in which a variable combination of post-concussion symptoms — such as headaches and dizziness — last for weeks and sometimes months after the injury that caused the concussion."


    "Traumatic brain injury (TBI), a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue. Symptoms of a TBI can be mild, moderate, or severe, depending on the extent of the damage to the brain. A person with a mild TBI may remain conscious or may experience a loss of consciousness for a few seconds or minutes. Other symptoms of mild TBI include headache, confusion, lightheadedness, dizziness, blurred vision or tired eyes, ringing in the ears, bad taste in the mouth, fatigue or lethargy, a change in sleep patterns, behavioral or mood changes, and trouble with memory, concentration, attention, or thinking. A person with a moderate or severe TBI may show these same symptoms, but may also have a headache that gets worse or does not go away, repeated vomiting or nausea, convulsions or seizures, an inability to awaken from sleep, dilation of one or both pupils of the eyes, slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation."
    Marcus Murphy, CPPM

  4. #4
    Join Date
    Apr 2007
    Columbia, MO


    Thank you Marcus! I often caution coders regarding reading too much into a diagnosis. A TBI is definitely not the same thing as a concussion. And having sustained several concussions is not the same as concussion syndrome. Coders need to not diagnose the patient. There may in fact not be a code for every condition the patient has ever had in the past, nor is it always relevant to need a code for something from the past. So my question is why are you wanting to code history of a concussion? Why is this relevant to this encounter, and if it is then it will be a V code for history of injury only, not history of TBI.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5

    Default TBI vs. Concussion

    This is an old thread, but in case anyone is searching for the answer (like I was), a concussion is a type of traumatic brain injury. The CDC specifically says "A concussion is a type of traumatic brain injury (TBI) caused by a bump, blow, or jolt to the head that can change the way your brain nomrally works." (http://www.cdc.gov/concussion/)

    So then a history of a concussion is most appropriately coded as history of TBI, or V15.52 (assuming no residual conditions remain). I know this has been a hot topic in the news lately so that may be why the additional clarity is available now.

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