ER Head Trauma ICD-10-CM Coding

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS CDC Leave a Comment

ER Head Trauma ICD-10-CM Coding

In the United States, our Emergency Rooms see a huge variety of patients, from insect bites to auto accidents and alike. The clinical area of “head injury” can be challenging for providers but also for the ICD-10-CM coding professionals.

According to the Centers for Disease Control and Prevention (CDC), the 2016 National Health Interview Survey based on parental report, 8.3% of boys and 5.6% of girls aged 3–17 years have ever had a significant head injury in their lifetime. As age increased, the percentage of children who have ever had a significant head injury also increased, peaking at 11.7% among children aged 15–17 years. In addition, Boys were more likely than girls to have ever had a significant head injury.

Traumatic Head Injury (THI) is defined by the CDC as: is an injury that affects how the brain works. THI and Traumatic brain injury or TBI are terms often used interchangeably. TBI is a major cause of death and disability in the United States. Anyone can experience a TBI, but data suggest that some groups are at greater risk of getting a TBI or having worse health outcomes after the injury. It is estimated that 176 Americans die each day due to TBI-related injuries and there were more than 223,000 TBI-related hospitalizations in 2019. Did you know that during 2009–2018, an estimated 596,972 ED visits for bicycle-related TBIs occurred in the United States? that’s a lot of data and clinical coding provides this.

Per the CDC a “Concussion” is defined as: A type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells. A concussion is the most common type of traumatic brain injury. For children and adults playing contact sports, like football, soccer, etc., we see encounters with a diagnosis of concussion.

The trauma registry works closely with medical record documentation and data collection to help understand trauma and trauma-related injuries better. A great resource to obtain more information about trauma registry is the American Trauma Society. The American Trauma Society is dedicated to the elimination of needless death and disability from injury. For over 5 years, ATS has served as an advocate for the trauma care system, trauma prevention programs, and the victims of trauma and their families throughout the United States. Trauma Registry uses ICD-10-CM/PCS classification system, External cause codes, Injury codes and Procedure codes.

In ICD-10-CM coding a documented diagnosis of “concussion” or “head injury” will be located in Chapter 19 and it is titled "Injury, Poisoning, and Certain Other Consequences of External Causes”, with a code range of S00–T88. Code subcategory S06 represents Intracranial injury and this includes traumatic brain injury (TBI). Per the tabular instructions you should “Code also any associated”:

open wound of head (S01.-)

skull fracture (S02.-)

The coding professional should also use an additional code, if applicable, to identify mild neurocognitive disorders due to known physiological conditions (F06.7-) S06 includes the following:

               S06.0     Concussion

               S06.1     Traumatic cerebral edema

               S06.2     Diffuse traumatic brain injury

       S06.3     Focus traumatic brain injury

               S06.4     Epidural hemorrhage

               S06.5     Traumatic subdural hemorrhage

               S06.6     Traumatic subarachnoid hemorrhage

               S06.8     Other specified intracranial injuries

               S06.9     Unspecified intracranial injury

               S06.A    Traumatic brain compression

For FY2023, the was a significant expansion within the code range S06. Examples of some new codes for FY2023 are these:

NEW S06.0XA Concussion with loss of consciousness status unknown

Concussion NOS

NEW S06.2XA Diffuse traumatic brain injury with loss of consciousness status unknown

Diffuse traumatic brain injury NOS

Subcategory S06.0 Concussion is further classified as without loss of consciousness, with loss of consciousness or 30 minutes or less, or with loss of consciousness of unspecified duration. The appropriate 7th character is to be added to each code from category S06:

A - initial encounter

D - subsequent encounter

S - sequela

It should be noted: 7th characters D and S do not apply to codes in category S06 with 6th character 7 - death due to brain injury prior to regaining consciousness, or 8 - death due to other cause prior to regaining consciousness. Always review the tabular closely, as there are inclusion terms and instructional notes that you do not want to miss.

The Centers for Medicare and Medicaid Services (CMS) states that a good approach to the coding of traumatic brain injury is to identify the Etiology, Location, Severity, and Encounter (ELSE).

Clinical documentation needs to be very specific and the level of consciousness and time should also be included. Having electronic health records that prompt to complete specific sections for this information can be extremely valuable. Also, having Clinical Documentation Integrity (CDI) assigned to the Emergency Room for documentation review and clarification (querying) can be very beneficial.

Some other key next steps for coding and CDI professionals to take is to have some documentation queries available for clarification and capture of specificity for concussion and THI/TBI. Talk to the Medical Director of the ED and also, conduct some 15-minute educational in-services to the Emergency Room or Trauma physicians (trauma team) on documentation.

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