Fact Sheet: Coding Guidance for TBI Page 5 of 5 Screening for. TBI ICD-10 codes (Z13.850) Diagnoses of TBI Initial or Subsequent and/or Sequela2. Visit. Initial TBI Diagnosis. 1. Primary Code: Brain Injury, S02.0xx, S02.x, S06.0-S06.3, or S09.x Category Other ICD-10 codes for symptoms (e.g., memory deficit R41.3)
2022 ICD-10-CM Diagnosis Code S06.301A S06.301A is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM S06.301A became effective on October 1, 2021.
If an injury occurred in the past several months or even years prior but the patient has never sought treatment for the injury previously, the first time the patient is SEEN for the injury is considered the initial treatment. An initial encounter does not refer to the first time the patient is seen by each clinician for that particular TBI.
SUBSEQUENT and/or Sequela TBI VISITS Additional Procedure Coding for TBI Care If the psychomotor Neurobehavioral Status Exam is completed, the provider should also utilize the CPT code 96116. This code includes the time for testing, interpreting, and a written report must be prepared. Coding is completed in 1-hr units but anything
*7th character of A, B, or missing (reflects initial encounter, active treatment); S09. 90— unspecified injury of head–is NOT included in the TBI definition....WISH: Traumatic Brain Injury (TBI) ICD-10-CM Codes.S02.0, S02.1Fracture of skullS06Intracranial injuryS07.1Crushing injury of skullT74.4Shaken infant syndrome2 more rows•Aug 23, 2021
ICD-10 code Z87. 820 for Personal history of traumatic brain injury is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
Diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter. S06. 2X9D is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM S06.
Therefore, assign code S06. 9x0A for documentation of traumatic brain injury (initial encounter) without further specification. However, a more specific code from category S06 should be assigned to identify the documented injuries such as concussion, cerebral edema, contusion, laceration, and hemorrhage.
Major or Minor Neurocognitive Disorder Due to Traumatic Brain Injury DSM-5 294.11 (F02. 8)
WISH Injury-Related Traumatic Brain Injury ICD-9-CM CodesICD-9-CM CodeDescription850.0-850.9Concussion851.00-854.19Intracranial injury, including contusion, laceration, and hemorrhage950.1-950.3Injury to the optic chiasm, optic pathways, or visual cortex959.01Head injury, unspecified3 more rows•Jul 5, 2020
This code includes the time for testing, interpreting, and a written report must be prepared. Coding is completed in 1-hr units but anything less than an 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 below diagnostic criteria does not predict functional or rehabilitative outcome of the patient. The level of injury is based on the status of the patient at the time of injury, based on observable signs such as level of consciousness, post-traumatic amnesia and coma scaling.