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H Fact Sheet: Coding Guidance for Traumatic Brain Injury Health Information Management Office of Informatics and Analytics IMPORTANT NOTE: This Fact Sheet denotes use of International Classification of Diseases, Tenth Revision (ICD-10) codes effective October 1, 2015. ALL PREVIOUS VERSIONS OF THIS FACT SHEET ARE RESCINDED. BACKGROUND: The Veterans Health Administration (VHA) has a need, to the best of its ability, to uniquely identify and report on Traumatic Brain Injury (TBI), its conditions, syndrome, and symptoms resulting from such injuries. VHA in conjunction with Department of Defense (DOD) have championed the development of TBI codes to more accurately capture and reflect TBI and its effects. CODING THE INITIAL ENCOUNTER: The ICD-10-CM codes will now provide the specificity of initial, subsequent, and/or sequela to describe the injury; however the seventh character of A will be used to identify the first time the patient is seen for the injury, regardless of when the injury took place. If an injury occurred in the past several months or even years prior but the patient has never sought treatment for the injury previously, the first time the patient is SEEN for the injury is considered the initial treatment. An initial encounter does not refer to the first time the patient is seen by each clinician for that particular TBI. Rather, an initial encounter is defined as the first time the patient is seen by any medical professional for the TBI, regardless of when the injury took place even if it occurred several weeks, months or years prior to the encounter, and for additional encounters where the patient is receiving âactive treatmentâ as defined in the ICD-10-CM Official Guidelines for Coding and Reporting. Clinical documentation must clearly indicate that the encounter coded is the initial encounter for that particular injury. For ICD-10-CM the appropriate 7th character will be added to the code to indicate the type of encounter: â¢ A initial encounter will be used while the patient is receiving active treatment for the condition 145
146 TRAUMATIC BRAIN INJURY IN VETERANS â¢ D subsequent encounter will be used for encounters after the patient has received active treatment of the condition and receiving routine care for the condition during the healing or recovery phase â¢ S sequela will be used for complications that arise as a direct result of the condition Initial Encounter: Veteran is seen for the first time at a VA facility for memory problems, as well as any additional encounters where the patient is receiving âactive treatmentâ. During the history the practitioner determines, on the basis of Veteranâs self-report, that there was brief loss of consciousness less than 30 minutes due to an Improvised Explosive Device (IED) blast. There is no evidence in the record of skull fracture. The Veteran reports that he has never sought treatment for the condition which is now causing significant problems at work. The practitioner selects the codes TBI Not Otherwise Specified (NOS) with loss of consciousness of 30 minutes or less, initial encounter (S06.9X1A) and the codes the for memory loss NOS (R41.3), and war operations involving explosion of improvised explosive device (IED), military personnel (Y36.230A). ICD-10 now codes based on loss of consciousness (LOC) time after the injury. In order to ensure the most accurate and appropriate level of coding, documentation must clearly state if there was an LOC due to the injury and the duration of the LOC. If documentation does not clearly define the LOC then unspecified state of consciousness must be coded. Please refer to your Health Information Management Coding Department for further guidance. FOLLOW UP CARE (Subsequent/Sequela Encounter): Subsequent encounter designation will be used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase, and sequela (late effect) designation will be used for complications that arise as a direct result of the condition. For follow up visits for late effects directly related to a previous TBI, the symptom code(s) that best represents the patientâs chief complaint or symptom(s) (e.g., headache, insomnia, vertigo) are coded, followed by the appropriate late effect code or sequela code. This will be the initial TBI injury code with the seventh character of S for sequela. Late effects include any symptom or sequelae of the injury specified as such, which may occur at any time after the onset of the injury. The External Causes of Morbidity (V01-Y99) code will also need to be added with a seventh character of S. The pairing of the symptom code and the late effect code is the ONLY WAY that symptoms can be causally and uniquely associated with TBI and is essential to the accurate classification of TBI. REHABILITATION: For TBI patients who receive inpatient or outpatient rehabilitation, the first-entered diagnosis is the purpose of the appropriate condition for which the rehabilitation service is being performed (e.g. neurological deficits, hemiparesis, etc.) and then the appropriate TBI code with the seventh character of D for subsequent encounter or S for sequela (S06.2, S06.3, or S06.9). The External Causes of Morbidity (V01-Y99) code will also need to be added with a seventh character of S.
APPENDIX H 147 USE of Z87.820 CODE: Z87.820 Personal history of traumatic brain injury was developed to indicate that previous TBI occurred and may impact current care. The Z87.820 code is not used in conjunction with the late effect codes; rather the Z code is used when no other code is available to reflect a previous TBI. Normally, the Z87.820 code is used to identify a personal history of injury with or without a confirmed diagnosis. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered. TBI SCREENING: Code Z13.850 should be used if TBI screening occurs at a visit, whether or not the screening is positive. A TBI diagnosis code should not be entered for a positive screen since a positive TBI screen does not indicate a TBI diagnosis. A TBI diagnosis code can only be entered for the encounter at which the diagnosis is made. Examples of ICD-10-CM Codes Typically Associated with TBI Acute Injuries Series Code Description S02.0xx Fractures of vault of skullârequires a seventh character for type of encounter and healing S02.1 Fractures of base of skullârequires two digits and a seventh character S06.0 Concussionârequires two digits and a seventh character S06.1 Traumatic cerebral edemaârequires two digits and a seventh character S06.2 Diffuse traumatic brain injuryârequires two digits and a seventh character S06.30 Focal traumatic brain injuryârequires an additional digit and a seventh character S06.31 Contusion and laceration of right cerebrumârequires an additional digit and a seventh character S06.32 Contusion and laceration of left cerebrumârequires an additional digit and a seventh character S06.33 Contusion and laceration of cerebrum, unspecifiedârequires an additional digit and a seventh character S09.x Unspecified intracranial injury (TBI NOS)ârequires an additional digit and a seventh character Late Effect Codes or Sequela Series Code Description S06.2 Diffuse traumatic brain injuryârequires two digits and a seventh character of S S06.30 Focal traumatic nrain injuryârequires an additional digit and a seventh character of S S09.x Unspecified intracranial injury (TBI NOS)ârequires an additional digit and a seventh character of S
148 TRAUMATIC BRAIN INJURY IN VETERANS Symptoms Involving Emotional State ICD-10 Code Symptom R45.0 Nervousness R45.4 Irritability and anger R45.87 Impulsiveness R45.86 Emotional lability R45.3 Demoralization and apathy R45.89 Other signs and symptoms involving emotional state Symptoms Involving Cognitive Function and Awareness ICD-10 Code Symptom R41.840 Attention and concentration deficit R41.841 Cognitive communication deficit R41.842 Visuospatial deficit R41.843 Psychomotor deficit R41.844 Frontal lobe and executive function deficit R41.89 Other signs and symptoms involving cognitive functions and awareness Note: Memory deficits will be coded as R41.3. Physical Effects of TBI ICD-10 Code Description G44.301 Posttraumatic headache, unspecified, intractable G44309 Posttraumatic headache, unspecified, not intractable G44.321 Chronic posttraumatic headache, unspecified, intractable G44.329 Chronic posttraumatic headache, unspecified, not intractable R42. Dizziness R43.0 Loss of smell (anosmia) R43.8 Other disturbance of smell and taste R47.82 Fluency disorder conditions classified elsewhere R47.81 Slurred speech R56.1 Posttraumatic seizures
APPENDIX H 149 Review all existing documentation, including Severity of TBI that from outside sources, to ensure that a previous TBI code has not been assigned. Clarify the patientâs documented symptoms by answering the below questions Duration: Has the symptom existed for days, The below diagnostic criteria does not predict functional weeks, or months? Has the symptom occurred or rehabilitative outcome of the patient. The level of only intermittently? Are there times of the day injury is based on the status of the patient at the time of when the symptom(s) is worse? Particularly injury, based on observable signs such as level of with regard to pain and fatigue, can the patient consciousness, posttraumatic amnesia and coma scaling. define if these symptoms occur 2 or 3 days per month or constantly? Onset: Can the patient recall exactly how the symptoms began? Were the triggering events, either physical or emotional? Was the onset subtle and gradual, or are there changing patterns? Location: Is the symptom localized or AOC â Alteration of consciousness/mental state diffuse? Can the patient localize the symptom LOC â Loss of consciousness by pointing to it? If the pain is diffuse, does it PTA â Post-traumatic amnesia involve more than one body area or quadrant? GCS â Glasgow Coma Scale Comorbidity: Does the patient have any diagnosed co-existing diagnoses? What is the relationship between the onset and severity of the co-existing illnesses and the symptoms of fatigue and/or pain? Are there co-morbid diagnoses? Are there new changes to the patientâs weight, mood, or diet?
150 TRAUMATIC BRAIN INJURY IN VETERANS Previous Episodes: If the symptoms are Additional Procedure Coding for TBI Care episodic, what is the pattern with regard to timing, intensity, triggering events, and response to treatment? Intensity and Impact: How severe are the If the psychomotor Neurobehavioral Status Exam is symptoms (1â10 rating scale)? Ask the patient completed, the provider should also utilize the CPT code to describe any new limitations they have 96116. This code includes the time for testing, experience compared to their usual life-style, interpreting, and a written report must be prepared. such as limitations in physical endurance or Coding is completed in 1-hr units but anything less than strength (e.g. climbing stairs, shopping, or an hour is claimed as 1 unit. Documentation must include sleep quality). clinically indicated portions of an assessment of thinking, reasoning and judgment (e.g., attention, acquired knowledge, language, memory and problem solving). Previous Treatment and Medications: Documentation Questions retrieved from the tables in the Request that patient bring copies of previous VA/DoD Clinical Practice Guidelines for Management of medical records regarding treatment of injury, Concussion/mTBI 2.0, Retrieved August 5, 2015, from or have patient authorize VA to receive copies VA/DoD Clinical Practice Guidelines and/or discuss medical history with previous clinician. Ask that the patient bring their medications bottles with them and document them within CPRS. Discuss with the patient which mediations have or have not been helpful.