Late Effect Codes or Sequela Series Code Description S06.2 Diffuse Traumatic Brain Injury- requires two digits and a seventh character of S S06.30 Focal Traumatic Brain Injury- requires an additional digit and a seventh character of S S09.x Unspecified Intracranial Injury (TBI NOS)- requires an additional digit and a seventh character of S
Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, sequela ICD-10-CM Diagnosis Code S06.2X2 Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes ICD-10-CM Diagnosis Code S06.2X4
S06.309S is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Short description: Unsp focal TBI w LOC of unsp duration, sequela.
2018/2019 ICD-10-CM Diagnosis Code S06.9X0S. Unspecified intracranial injury without loss of consciousness, sequela. S06.9X0S is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Z87. 820 - Personal history of traumatic brain injury. ICD-10-CM.
There are multiple sequelae of mild head injury, including headaches of multiple types, cranial nerve symptoms and signs, psychologic and somatic complaints, and cognitive impairment. Rare sequelae include hematomas, seizures, transient global amnesia, tremor, and dystonia.
1. TBI diagnostic code: S06.
ICD-10 Code for Unspecified focal traumatic brain injury- S06. 30- Codify by AAPC.
After TBI, the most frequent diagnoses were major depression and anxiety disorders (i.e., post-traumatic stress disorder (PTSD), obsessive-compulsive disorder and panic disorder).
The neurobehavioral sequelae of traumatic brain injury consist of a spectrum of somatic and neuropsychiatric symptoms. The neuropsychiatric symptoms are divided into cognitive and behavioral presentations.
1 Post-traumatic stress disorder. Arises as a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone.
ICD-10 code S06. 0X9A for Concussion with loss of consciousness of unspecified duration, initial encounter is a medical classification as listed by WHO under the range - Injury, poisoning and certain other consequences of external causes .
Focal brain injury refers to areas of localised damage and includes contusions and lacerations. Contusions are multiple small haemorrhages in the surface layers of the brain (i.e. bruises). They can occur at the site of impact and/or at the opposite side of the brain from the site of impact.
ICD-10-CM Code for Postconcussional syndrome F07. 81.
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
Unspecified injury of head, initial encounter S09. 90XA 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 S09. 90XA became effective on October 1, 2021.
Use secondary code (s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code. Type 1 Excludes.
The 2022 edition of ICD-10-CM S06.9X0S became effective on October 1, 2021.
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.
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.
For ICD-10-CM the appropriate 7thcharacter will be added to the code to indicate the type of encounter: A initial encounter will be used while the patient is receiving active treatment for the condition D subsequent encounter will be used for encounters after the patient has received active treatment of the condition and receiving routine care for the condition during the healing or recovery phase S sequela will be used for complications that arise as a direct result of the condition
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.
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).
R43.8 Other Disturbance of Smell and Taste
The ‘S’ is added only to the injury code, not the sequela code. The seventh character ‘S’ identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.”.
The sequela code may also be expanded at the fourth, fifth, or sixth character levels to include the manifestation
There is no time limit on when a sequela code can be used. The residual effect may be present early or may occur months or years later. Two codes are generally required: one describing the nature of the sequela and one for the sequela. The code for the acute phase of the illness or injury is never reported with a code for the late effect.
Rationale: Scar contractures due to burn injury are reported with code L90.5 that is the first-listed or principal diagnosis and the burn injury is reported as a secondary code to identify the cause of the sequela.
S93.412S Sprain of calcaneofibular ligament of the left ankle, sequela