Skip to main content

Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans (2019) / Chapter Skim
Currently Skimming:

Appendix H: Fact Sheet: Coding Guidance for Traumatic Brain Injury
Pages 145-150

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 145...
... 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 "active treatment" as defined in the ICD-10-CM Official Guidelines for Coding and Reporting.
Read the entire page →
From page 146...
... 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)
Read the entire page →
From page 147...
... 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 skull -- requires a seventh character for type of encounter and healing S02.1 Fractures of base of skull -- requires two digits and a seventh character S06.0 Concussion -- requires two digits and a seventh character S06.1 Traumatic cerebral edema -- requires two digits and a seventh character S06.2 Diffuse traumatic brain injury -- requires two digits and a seventh character S06.30 Focal traumatic brain injury -- requires an additional digit and a seventh character S06.31 Contusion and laceration of right cerebrum -- requires an additional digit and a seventh character S06.32 Contusion and laceration of left cerebrum -- requires an additional digit and a seventh character S06.33 Contusion and laceration of cerebrum, unspecified -- requires an additional digit and a seventh character S09.x Unspecified intracranial injury (TBI NOS)
Read the entire page →
From page 148...
... 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
Read the entire page →
From page 149...
... 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?
Read the entire page →
From page 150...
... . 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.
Read the entire page →

Key Terms

  • traumatic brain
  • brain injury
  • additional digit
  • late effect
  • previous tbi

  • initial encounter
  • tbi diagnosis
  • subsequent encounter
  • focal traumatic
  • effect codes

  • tbi code
  • diagnosis code
  • practice guidelines
  • effect code
  • additional encounters

  • information management
  • active treatment
  • late effects
  • clinical practice
  • improvised explosive

  • diffuse traumatic
  • received active
  • health information
  • explosive device
  • personal history

  • symptom code
  • war operations
  • series code
  • medical records
  • previous treatment


    • This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
    More information on Chapter Skim is available.