ICD-10 Codes for Traumatic Brain Injury (TBI)

ICD-10 Codes for Traumatic Brain Injury

About 1.7 million cases of TBI occur in the U.S. every year, according to the American Association of Neurological Surgeons (AANS).

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Traumatic brain injury (TBI) is defined as a blow to the head or a penetrating head injury that disrupts the normal function of the brain.

According to the American Association of Neurological Surgeons (AANS), about 1.7 million cases of TBI occur in the U.S. every year, with approximately 5.3 million people living with a disability caused by TBI. The CDC reports that in 2014, an average of 155 people in the United States died each day from injuries that include a TBI. As physicians focus on providing care, they can rely on coding and medical billing services to report the appropriate code to report diagnosis and treatment.

March is Brain Injury Awareness Month and the theme for 2018-2020 is “Change Your Mind.” The campaign provides a platform for educating people about incidence of brain injury and the needs of people with brain injuries and how to support their families.

TBI – Causes and Types TBI usually occurs when the head or body receives a violent blow or jolt or an object pierces the skull and enters brain tissue. Falls, motor vehicle accidents and being struck by or against an object are the leading causes of TBI. TBI disrupts the normal function of the brain.

Depending on the extent of damage, TBI can be mild, moderate or severe.

Mild cases may affect the brain cells temporarily and cause a brief change in mental state or consciousness.

Mild TBIs or concussions are the most

common type. Moderate to severe TBI may include any of the signs and symptoms of mild injury, as well as bruising, torn tissues, bleeding and other physical damage to the brain, which may appear within a few hours to

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days following the head injury. Severe injuries can result in extended periods of unconsciousness, coma or death.

Diagnosis Patients with traumatic brain injuries usually need detailed and quick evaluation in the emergency room. This may involve the following: -

Cardiac and pulmonary function followed by an exam of the whole body.

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Systematic neurological examination to reveal evidence of brain injury..

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Radiological tests – While plain x-ray is usually enough to evaluate patients with only mild neurological dysfunction, brain imaging with CAT scan, MRI, SPECT and PET scan are necessary to detect crucial lesions such as the presence of blood and fractures.

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Cognitive evaluation and formal neuropsychological testing. The Glasgow Coma Scale helps medical personnel to assess the initial severity of a brain injury by checking a person's level of consciousness (such as the ability to follow directions and move their eyes and limbs).

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Evaluations by physical, occupational and speech therapists can help shed light on the specific concerns.

ICD-10 Codes for Traumatic Brain Injury The ICD codes for TBI are as follows: S02.0 Fracture of vault of skull S02.1 Fracture of base of skull S02.7-S02.9 Multiple fractures involving skull and facial bones

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Fractures of other skull and facial bones Fracture of skull and facial bones, part unspecified S04.0-S04.9 Injury of cranial nerves S06.0-S06.9 Concussion Traumatic cerebral oedema Diffuse brain injury Focal brain injury Epidural haemorrhage Traumatic subdural haemorrhage Traumatic subarachnoid haemorrhage Intracranial injury with prolonged coma Other intracranial injuries Intracranial injury, unspecified S07.1 Crushing injury of skull S07.8 Crushing injury of other parts of head S07.9 Crushing injury of head, part unspecified S09.7-S09.9 Multiple injuries of head Other specified injuries of head Unspecified injury of head T02.0 Fractures involving head with neck T04.0 Crushing injuries involving head with neck T06.0 Injuries of brain and cranial nerves with injuries of nerves and spinal cord at neck level Points to Note: Here is some important guidance on ICD-10 coding for TBI from a report published by the National Academy of Sciences in 2019 (https://www.ncbi.nlm.nih.gov/books/NBK542610):

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o ICD-10 codes are assigned based on loss of consciousness (LOC) time after the injury. To ensure the most accurate and appropriate level of coding, documentation must clearly indicate 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. o Code Z87.820 Personal history of traumatic brain injury is usually used identify a personal history of injury with or without a confirmed diagnosis. o Code Z13.850 should be used if TBI screening occurs at a visit, whether or not the screening is positive. A positive screen does not denote a TBI diagnosis. A TBI ICD 10 code should be reported only for the encounter at which the diagnosis is made. o Clinical documentation must clearly indicate that the encounter coded – initial (A), subsequent (D) or sequel (S).

The Centers for Disease Control states that everyone is at risk for TBI, especially children and older adults. Many Americans are living with permanent disabilities caused by TBI that includes a loss of independence and lack of direction. While it may not be possible to prevent all traumatic brain injuries, supporting the March Change Your Mind campaign can help create an ongoing dialogue to raise awareness about the risks associated with brain injury and its incidence, and improve support for people with brain injuries and their families.

Experienced medical billing service providers have expert coders on board who can help physicians report the appropriate codes in the billing process.

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