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February 27, 2012

Coding for Traumatic Brain Injury
For The Record
Vol. 24 No. 4 P. 28

A traumatic brain injury (TBI) occurs when a sudden trauma causes damage to the brain 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, Intracranial injury of other and unspecified nature. The fourth digit subcategory identifies whether the intracranial injury mentions an open intracranial wound.

If the TBI is documented only as a closed head injury without further description, assign code 959.01. A closed head injury occurs when a person receives a hard blow to the head from striking an object, but the object did not break the skull. However, if there was a loss of consciousness in the case of either a closed head injury or a TBI, assign a code from category 850, Concussion, instead of either 959.01 or a code from category 854.

If a TBI or a closed head injury included additional documented injuries, then 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.

A fifth digit subclassification is required for categories 851 to 854 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. (Use this fifth digit to designate when a patient is unconscious and dies before regaining consciousness, regardless of the duration of the loss of consciousness.);

• 6, with loss of consciousness of unspecified duration; and

• 9, with concussion, unspecified.

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 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.

Symptoms of a brain injury can range from mild to moderate to severe depending on the extent of brain damage. Symptoms of a mild brain injury include a brief loss of consciousness (few seconds to a few minutes); being dazed, confused, or disoriented; headache; memory or concentration problems; dizziness or loss of balance; nausea or vomiting; blurred vision; ringing in the ears; bad taste in the mouth; sensitivity to light or sound; mood changes or mood swings; feeling depressed or anxious; fatigue or drowsiness; sleeping more than usual or difficulty sleeping; and trouble with memory, concentration, attention, or thinking.

Symptoms of a moderate or severe brain injury include the same symptoms of a mild brain injury; a more severe and persistent headache; nausea or 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.

To diagnose a TBI, the physician assesses a patient’s ability to follow directions regarding blinking his or her eyes or moving extremities. In addition, the physician may order X-rays or a CT scan to determine if the TBI can be further identified as a brain hemorrhage, brain hematoma, contused (bruised) brain tissue, or brain tissue swelling.

Although little can be done to reverse the brain damage caused by the trauma, treatment is directed at preventing further damage. Goals of treatment include ensuring proper oxygen supply to the brain, maintaining adequate blood flow, and controlling blood pressure.

Some TBIs require surgery to remove or repair the hemorrhage or hematoma.

Coding and sequencing for TBI 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 more than 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.


Coding for Closed Head and Traumatic Brain Injuries in ICD-10-CM
Closed head injury is indexed under the main term “Injury” in the Alphabetic Index with subterms as follows:


Head S09.90

With loss of consciousness S06.9-

Specified NEC S09.8

Therefore, based on the index, code S09.90xA is assigned for documentation of closed head injury (initial encounter). If documentation supports that the patient had loss of consciousness with the closed head injury, assign a code from subcategory S06.9, Unspecified intracranial injury. The sixth character will identify how long the patient was unconscious.

Subcategory S06.9 is also assigned for unspecified brain injury. Although “head” and “brain” sound like similar terms, they are classified differently in ICD-10-CM. Therefore, assign code S06.9x0A for documentation of traumatic brain injury (initial encounter) without further specification. However, a more specific code from category S06 should be assigned to identify the documented injuries such as concussion, cerebral edema, contusion, laceration, and hemorrhage. Instructional notes also state to code any associated open wound of head (S01.-) and skull fracture (S02.-).

— AH