TBI

Brenda

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

Brenda

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

Nancy.Wolverton@kindred.com

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

Brenda

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

jamie.seghers@amedisys.com

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

Nancy.Wolverton@kindred.com

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

Sue

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

Sue

We use S06.9XOS (as we don't have a lot of history)
Sue