| ICD-10 Code | Symptom |
|---|---|
| R41.840 | Attention and concentration deficit |
| R41.841 | Cognitive communication deficit |
ICD-10-CM Diagnosis Code S06.2X7 Diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness Diffuse TBI w LOC w death due to brain injury bf consc ICD-10-CM Diagnosis Code S06.307
cognitive deficits following (sequelae of) cerebral hemorrhage or infarction ( ICD-10-CM Diagnosis Code I69.01. Cognitive deficits following nontraumatic subarachnoid hemorrhage 2016 2017 - Deleted Code 2017 - New Code 2018 2019 Non-Billable/Non-Specific Code.
Mild neurocognitive disorder due to traumatic brain injury. Minimal cognitive impairment. ICD-10-CM G31.84 is grouped within Diagnostic Related Group (s) (MS-DRG v38.0): 056 Degenerative nervous system disorders with mcc. 057 Degenerative nervous system disorders without mcc.
The diagnosis code I69.311 indicates Memory deficit following cerebral infarction. Specific diagnosis codes should only be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition.
Diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela. S06. 2X9S 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.
84.
Cognitive impairment is a common consequence of traumatic brain injury (TBI) and a substantial source of disability. Across all levels of TBI severity, attention, processing speed, episodic memory, and executive function are most commonly affected.
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.
Cognitive deficit is an inclusive term used to describe impairment in an individual's mental processes that lead to the acquisition of information and knowledge, and drive how an individual understands and acts in the world. The following areas constitute domains of cognitive functioning: Attention. Decision making.
ICD-10 Code for Mild cognitive impairment, so stated- G31. 84- Codify by AAPC.
Judgment, Reasoning, Problem-Solving, and Self-Awareness. Judgment, reasoning, problem-solving and self-monitoring are complex cognitive skills that are often affected after a TBI.
After a TBI it is common for people to have problems with attention, con- centration, speech and language, learning and memory, reasoning, planning and problem-solving. A person with TBI may be unable to focus, pay attention, or attend to more than one thing at a time.
The frontal lobeThe frontal lobe is important for cognitive functions and control of voluntary movement or activity.
Z87. 820 - Personal history of traumatic brain injury. ICD-10-CM.
Injury, unspecified ICD-10-CM T14. 90XA is grouped within Diagnostic Related Group(s) (MS-DRG v39.0): 913 Traumatic injury with mcc. 914 Traumatic injury without mcc.
Cognitive deficits following cerebral infarction 1 I69.31 should not be used for reimbursement purposes as there are multiple codes below it that contain a greater level of detail. 2 The 2021 edition of ICD-10-CM I69.31 became effective on October 1, 2020. 3 This is the American ICD-10-CM version of I69.31 - other international versions of ICD-10 I69.31 may differ.
The 2022 edition of ICD-10-CM I69.31 became effective on October 1, 2021.
Mild neurocognitive disorder co-occurrent and due to human immunodeficiency virus infection. Mild neurocognitive disorder co-occurrent and due to huntington's disease.
The 2022 edition of ICD-10-CM G31.84 became effective on October 1, 2021.
The R41.84- series of ICD-10-CM codes is most commonly used to report cognitive deficits following TBI and includes specific codes for attention and concentration, cognitive communication , and frontal lobe and executive function deficits. Report this series of codes in conjunction with the S06- series to describe the type of TBI giving rise to the cognitive deficits. SLPs should always consult the medical record or referring physician to confirm the appropriate code to describe the type of TBI.
Use the I69- series of ICD-10-CM codes to report cognitive deficits following cerebrovascular disease. Each category of cerebrovascular disease—nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage, other nontraumatic intracranial hemorrhage, cerebral infarction, other cerebrovascular diseases, unspecified cerebrovascular diseases—includes codes for specific cognitive deficits, including memory, attention and concentration, frontal lobe and executive function, and cognitive-social deficits. The I69- series of codes is one of the few used by SLPs that incorporate both the medical diagnosis and treating diagnosis in one category. SLPs should always consult the medical record or referring physician to confirm the type of cerebrovascular disease before selecting an I69- code.
Policies are often limited to services for patients diagnosed with specific medical conditions—such as stroke or traumatic brain injury (TBI)—and may also exclude cognitive services for specific conditions such as mild TBI, developmental disorders, or neurodegenerative diseases.
Private Insurance. Like Medicaid, each private insurance plan can decide whether they will reimburse for cognitive therapy services. It is common for insurance plans to limit coverage to cognitive therapy for deficits due to specific medical conditions (e.g., moderate to severe TBI, stroke, or encephalopathy).
If there is no LCD in your state , work with the local MAC to verify coverage guidelines for cognitive services.
TBI SCREENING:Code Z13.850 should be used if TBI screening occurs at a visit, whether or not the screening is positive. A TBI diagnosis code should not be entered for a positive screen since a positive TBI screen does not indicate a TBI diagnosis. A TBI diagnosis code can only be entered for the encounter at which the diagnosis is made.
Unspecified intracranial injury (TBI NOS)—requires an additional digit and a seventh character
USE of Z87.820 CODE:Z87.820 Personal history of traumatic brain injury was developed to indicate that previous TBI occurred and may impact current care. The Z87.820 code is not used in conjunction with the late effect codes; rather the Z code is used when no other code is available to reflect a previous TBI. Normally, the Z87.820 code is used to identify a personal history of injury with or without a confirmed diagnosis. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
The pairing of the symptom code and the late effect code is the ONLY WAY that symptoms can be causally and uniquely associated with TBI and is essential to the accurate classification of TBI.
FOLLOW UP CARE (Subsequent/Sequela Encounter):Subsequent encounter designation will be used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase, and sequela (late effect) designation will be used for complications that arise as a direct result of the condition. For follow up visits for late effects directly related to a previous TBI, the symptom code(s) that best represents the patient's chief complaint or symptom(s) (e.g., headache, insomnia, vertigo) are coded, followed by the appropriate late effect code or sequela code. This will be the initial TBI injury code with the seventh character of S for sequela. Late effects include any symptom or sequelae of the injury specified as such, which may occur at any time after the onset of the injury. The External Causes of Morbidity (V01-Y99) code will also need to be added with a seventh character of S.
CODING THE INITIAL ENCOUNTER:The ICD-10-CM codes will now provide the specificity of initial, subsequent, and/or sequela to describe the injury; however the seventh character of A will be used to identify the first time the patient is seen for the injury, regardless of when the injury took place. 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.
Focal traumatic nrain injury—requires an additional digit and a seventh character of S
For example, exams performed because of a history of memory loss that reveal normal memory and other neurocognitive functions should use the diagnosis code R41.1 Anterograde amnesia or R41.3 Other amnesia/memory loss NOS, depending on the clinical history. Exams performed because of a history of anomia would be coded as R48.8 Other symbolic dysfunctions, as indicated by searching for the term anomia in the alphabetic index. Exams performed because of subjective complaints of memory loss that reveal normal memory function and depression should use a diagnosis code of R41.1 anterograde amnesia or R41.3 Other amnesia/memory loss NOS as the primary diagnosis, followed by an appropriate diagnosis code for depression. The neuropsychological examination was performed to objectively and quantitatively evaluate memory function; it was not performed to evaluate for depression.
It is necessary to understand the terminology of the ICD-10-CM in order to interpret diagnosis entries and assign diagnosis codes accurately.
The International Classification of Diseases (ICD) is a system of diagnostic codes for classifying morbidity due to diseases, external causes of injury, signs and symptoms, and abnormal findings. Its full official name is the International Statistical Classification of Diseases and Related Health Problems. It is published by the World Health Organization (WHO) and is used worldwide for morbidity and mortality statistics. The ICD is revised periodically and is currently in its 10th revision, the ICD-10 ( World Health Organization ).
For encounters/visits in which patients receive diagnostic services only, the rule is to first sequence the diagnosis, condition, problem, or other reason chiefly responsible for the service.
The process of diagnosis coding generally involves (1) determining a diagnosis by use of diagnostic criteria, and (2) communicating that diagnosis by a diagnosis code or multiple codes. In the situation in which a neuropsychological examination is performed but a specific etiologic diagnosis is not established, the signs and/or symptoms that led to or were revealed by the examination are communicated by a diagnosis code. This article summarizes this process, and emphasizes that a firm understanding of diagnosis coding is essential to the competent and ethical practice of neuropsychological assessment.
The ICD-10-CM Official Guidelines for Coding and Reporting describe the conventions and rules for coding using the ICD-10-CM, and complement the coding instructions provided within the ICD-10-CM itself. This is the official set of guidelines and the only one approved by the four organizations comprising the Cooperating Parties for the ICD-10-CM (the American Hospital Association [AHA], the American Health Information Management Association [AHIMA], Centers for Medicare and Medicaid Services [CMS], and the National Center for Health Statistics [NCHS]). The Guidelines trump all other sources of information regarding coding, other than the instructional notes provided within the ICD-10-CM itself. Adherence to the guidelines when assigning ICD-10-CM diagnosis codes is required under HIPAA. Accurate ICD-10-CM coding, therefore, requires familiarity with both the ICD-10-CM itself and the Guidelines. Diagnosis coding information and recommendations that come from other sources, including professional organizations, therefore should be used with caution and checked against the ICD-10-CM instructional notes and the Official Guidelines.
First, the practitioner determines the diagnosis by using diagnostic criteria. Second, the practitioner locates the condition in the alphabetic index by looking for the main term, reviewing the sub-terms, and reading the instructional notes. Third, the practitioner consults with the Tabular List to verify the code, identify the highest level of specificity, review the instructional notes, and review the chapter-specific and category-specific coding guidelines . If a definitive diagnosis has not been established or confirmed by the examination, then the practitioner codes for the sign (s) and/or symptom (s) that led to (and justify the medical necessity of) the examination or were revealed by the examination.