800-804 & 850-854 Series Codes Description Fractures of vault of skull - require a fourth and fifth digit Fractures of base of skull - require a fourth and fifth digit Fracture of face bones - require a fourth and fifth digit Other and unqualified skull fractures - require a fourth and fifth digit Multiple fractures involving skull or face with other bones - require a fourth and fifth digit Concussion - require a fourth and fifth digit Cerebral laceration and contusion - require a fourth and fifth digit Subarachnoid, subdural, and extradural hemorrhage, following injury - require a fourth and fifth digit Other and unspecified intracranial hemorrhages following injury - require a fourth and fifth digit Intracranial injuries of other and unspecified nature - require a fourth and fifth digit
Injury Related to Global War on Terrorism Unknown Mild Level of Severity
V-Code (must be used with all TBI encounters) V15.52_0 V15.52_1 V15.52_2 V15.52_3 V15.52_4 V15.52_5 V15.52_6 V15.52_7 V15.52_8 V15.52_9 V15.52_A V15.52_B V15.52_C V15.52_D V15.52_E V15.52_F
Moderate
Severe
Penetrating
Personal history of traumatic brain injury NOT otherwise specified Yes X Yes X Yes X Yes Yes No X No X No X No No Unknown X Unknown X Unknown X Unknown Unknown
X X
X X
X X
905.0 907.0
Late Effect Code (must be used with all follow-up TBI encounters) Late effect of intracranial injury with skull or facial fracture Late effect of intracranial injury without skull or facial fracture Series Code 799.21 799.22 799.23 799.24 799.25 799.29 Emotional/ Behavioral Symptom Codes Description Nervousness Irritability Impulsiveness Emotional Lability Demoralization and Apathy Other Signs and Symptoms Involving Emotional State E&M Coding for TBI Care Description New Outpatient-level 3 New Outpatient-level 4 Established Outpatient-level 3 Established Outpatient-level 4 Procedure Code for TBI Care Neurobehavioral status exam
Common Symptoms Associated with TBI Code Description Hearing 389.9 Hearing Loss, Unspecified 388.42 Hyperacusis 388.3 Tinnitus Neurologic 780.4 Dizziness, Lightheadedness 784.0 Headache 780.93 Memory Loss, NOS 438.85 Vertigo Psychiatric 308.9 Acute Stress Reaction, Unspecified 300 Anxiety /Irritability 311 Depression Sleep 780.5 Sleep disturbance 780.52 Insomnia Vision 368.8 Blurred Vision, NOS 368.13 Photophobia Other/General 780.7 Malaise and Fatigue 787.02 Nausea
http://www.dcoe.health.mil/ForHealthPros/Resources.aspx
Series Code 99203 99204 99213 99214 96116
V80.01
TBI Screening Code Special Screening for TBI
Version 5.0: September 2010
DoD ICD-9 CM CODING GUIDANCE FOR TRAUMATIC BRAIN INJURY
DoD Definition of TBI A traumatically induced structural injury and/or physiological disruption of brain function as a result of external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: • Any period of loss of or a decreased level of consciousness; • Any loss of memory for events immediately before or after the injury; • Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.); • Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient; • Intracranial lesion. External forces may include any of the following events: the head being struck by an object, the head striking an object, the brain undergoing an acceleration/deceleration movement without direct external trauma to the head, a foreign body penetrating the brain, forces generated from events such as blast or explosion, or other force yet to be defined. (Department of Defense, 2007)
Severity of TBI The level of injury is based on the status of the patient at the time of injury based on observable signs. Severity of injury does not predict functional or rehabilitative outcome of the patient. Mild Normal structural imaging LOC = 0-30 min AOC = a moment up to 24 hrs PTA = 0-1 day Moderate Severe Normal or abnormal Normal or abnormal structural imaging structural imaging LOC >30 min and LOC > 24 hrs < 24 hours AOC >24 hours. Seveity based on other criteria PTA >1 and <7 PTA > 7 days days
AOC – Alteration of consciousness/mental state LOC – Loss of consciousness PTA – Post-traumatic amnesia
Look Before You Code Prior to using a TBI ICD-9 code, the provider should ensure that the patient does not have an existing TBI diagnosis code for the current injury. Previous TBI diagnoses are recorded in the problem list. In the event the patient does not have a previously coded TBI for the present injury, an appropriate provider should enter the correct 800 series ICD-9 code and the correct V15.52_X code during the visit. This coding should occur even if the patient denies TBI-related symptoms. Personal History of TBI Codes & Late Effect Codes Providers must always utilize the appropriate personal history V15.52_X code with any diagnosed TBI encounter, initial or follow-up. This is crucial for TBI surveillance purposes. In addition, all follow-up TBI encounters must be coded with one of two late effect codes: 905.0 (late effect of intracranial injury with skull or facial fracture) or 907.0 (late effect of intracranial injury without skull or facial fracture).
Procedure Coding for TBI Care The CPT code 96116 is used if the Psychomotor Neurobehavioral Status Exam is completed. This code includes the time for testing, interpreting and preparing the report. While many clinicians may be able to complete this within minutes during a quick office screen, coding is completed in one hour units. Anything less than one hour is claimed as 1 unit. Documentation must include clinically indicated portions of an assessment of thinking, reasoning and judgment (e.g., attention, acquired knowledge, language, memory and problem solving). The areas most often affected by TBI include attention, memory and problem solving so these areas should be screened if there are cognitive complaints. Other areas may be assessed as clinically indicated. This procedure may be completed in follow-up visits as long as the documentation is supportive (history and documented screening examination).
Emotional/ Behavioral Symptom Codes The 799-series codes allow providers to code emotional/behavioral symptoms without using mental health diagnosis codes. These codes do not replace mental health diagnosis codes. Providers should use these codes when they observe the symptoms but a mental health diagnosis is not established. While these codes are intended to be used for TBI symptoms, they are not limited to TBI. http://www.dcoe.health.mil/ForHealthPros/Resources.aspx Version 5.0: September 2010
