June 9 , 2008

Coding for Brain Injury
For The Record
Vol. 20 No. 12 P. 27

A traumatic brain injury (TBI) occurs when the brain is damaged as a result of the head hitting an object or vice versa.

TBI without further specification is classified to a code from ICD-9-CM category 854. A fifth digit subclassification is required to identify loss of consciousness, if any, and the length of time as follows:

• 0 — unspecified state of consciousness;

• 1 — with no loss of consciousness;

• 2 — with brief (less than one hour) loss of consciousness;

• 3 — with moderate (one to 24 hours) loss of consciousness;

• 4 — with prolonged (more than 24 hours) loss of consciousness and return to preexisting conscious level;

• 5 — with prolonged (more than 24 hours) loss of consciousness without return to preexisting conscious level;

• 6 — with loss of consciousness of unspecified duration; or

• 9 — with concussion, unspecified.

If the traumatic injury is documented as a closed head injury without further description, assign code 959.01. However, if there was a loss of consciousness with either a closed head injury or a brain injury, assign a code from category 850, Concussion, instead of either 959.01 or 854.xx. Concussion will be discussed in more detail later.
If the TBI or closed head injury had additional injuries documented, a more specified code should be assigned as follows:

• Category 851, Cerebral laceration and contusion;

• Category 852, Subarachnoid, subdural, and extradural hemorrhage, following injury; or

• Category 853, Other and unspecified intracranial hemorrhage following injury.

Symptoms
Symptoms of a brain injury can vary, depending on the extent of brain damage. Symptoms of a mild brain injury may include a brief loss of consciousness (few seconds to a few minutes), headache, confusion, lightheadedness, dizziness, blurred vision, ringing in the ears, bad taste in the mouth, fatigue or lethargy, change in sleep patterns, behavioral or mood changes, and trouble with memory, concentration, attention, or thinking.

Symptoms of a moderate or severe brain injury may include the same as a mild brain injury, more severe and persistent headache, repeated vomiting or nausea, seizures, inability to awaken from sleep, dilation of one or both pupils, slurred speech, weakness or numbness in the extremities, loss of coordination, and increased confusion, restlessness, or agitation.

Diagnosis
To diagnose a TBI, the physician assesses the patient’s ability to follow directions in regard to blinking their eyes or moving their extremities. In addition, the physician may order x-rays or a CT scan to determine if the traumatic brain injury can be further identified as brain hemorrhage, hematoma of the brain, contusion (bruised) brain tissue, or brain tissue swelling.

Treatment
Although little can be done to reverse any brain damage, treatment is directed at preventing further damage. Treatment goals include insuring proper oxygen supply to the brain, maintaining adequate blood flow, and controlling blood pressure. Some TBIs require surgery to remove or repair a hemorrhage or hematoma.

Concussion
A concussion results from a blow to the head severe enough to cause a transient or prolonged alteration of consciousness, which may be followed by amnesia, vertigo, nausea, and weak pulse. The concussion may affect the patient’s memory, judgment, reflexes, speech, balance, and coordination. Concussions do not always involve a loss of consciousness.

Concussion not further specified is classified to category 850. The fourth digit subcategory will identify loss of consciousness, if any, and the length of time. If the concussion is further specified as a cerebral contusion, laceration, or hemorrhage, it is classified to categories 851 to 853. A code from category 850 is not assigned with a code from categories 851 to 853. Category 854 is used when the brain injury is not classifiable to categories 850 to 853. A closed head injury described as a concussion is classified to the appropriate code in category 850. “When the head injury is specified as concussion, a code from category 854, Intracranial injury of other and unspecified nature or code 959.01, Head injury, unspecified, is inappropriate” (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 10). Patients with concussions usually recover completely within 24 to 48 hours.

Coding and sequencing for brain injury are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.