TBI

I need to understand how to assign a code for a TBI with or without a loss of consciousness. Any advice is appreciated.

Brenda Hoss
Coder

Comments

  • edited May 2017
    I have to assign a code for hx tbi with cognitive deficit. So I believe I need to use an s for sequela. R41.81 codes wouldn't show the late effect. Any other ideas?


    Brenda Hoss
    Coder
  • TBI means traumatic brain injury.
    Your codes will come from the injury category. Any deficit charged to this injury, you will use an "S" 7th character to the injury code if the TBI (an acute event) has been documented as "resolved" (the acute injury no longer is progressing) and now with deficits.
    List the deficits first that your POC is addressing and has physician documentation of, then the underlying injury code with the "S".

    Nancy Wolverton RN,CCM
    QR Specialist, Central Office
    5800 West 10th St., Suite 300
    Little Rock, AR. 72205
    Ph# 501-280-4913
    Fax# 501-280-4385
    Nancy.Wolverton@arkansas.gov
  • edited May 2017
    But my question is that medical recds don't show if patient had a loc or not. So I need a tbi with unspecified loc.


    Brenda Hoss
    Coder
  • If there are no residuals and we are just wanting to show the patient has had a TBI use history of TBI Z87.820.

    Thanks,
    Jamie Seghers, HCS-D, BCHH-C, COS-C, ICD-10-CM Certified Trainer
    Medical Coding Manager
    Office Phone: 225-299-3763
    Cisco ext. 3763
    Fax: 877-751-5987
  • You will need to query the physician.
    There is no unspecified brain injury code with unknown LOC vs no LOC as you found out

    Nancy Wolverton RN,CCM
    QR Specialist, Central Office
    5800 West 10th St., Suite 300
    Little Rock, AR. 72205
    Ph# 501-280-4913
    Fax# 501-280-4385
    Nancy.Wolverton@arkansas.gov
  • SueSue
    edited May 2017
    I work at Private Duty Office and have many TBI's we use S06.9XOS (as we don't have a lot of history)
    code deficit separately.
    Sue
  • SueSue
    edited May 2017
    We use S06.9XOS (as we don't have a lot of history)
    Sue
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