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 2019 edition of ICD-10-CM S09.90XA became effective on October 1, 2018.
Used for medical claim reporting in all healthcare settings, ICD-10-CM is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, abnormal findings, signs and symptoms, injuries, external causes of injuries and diseases, and social circumstances.
90 - Unspecified hearing loss, unspecified ear.
Therefore, based on the index, code S09. 90xA is assigned for documentation of closed head injury (initial encounter).
S09. 90XA Unspecified injury of head, initial encounter - ICD-10-CM Diagnosis Codes.
S06.9X7 Unspecified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness.
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.
Our physicians have used IDC-10 code F07. 81 as the primary diagnosis for patients presenting with post concussion syndrome.
Traumatic brain injury (TBI) is a sudden injury that causes damage to the brain. It may happen when there is a blow, bump, or jolt to the head. This is a closed head injury. A TBI can also happen when an object penetrates the skull.
ICD-10 Code for Unspecified focal traumatic brain injury- S06. 30- Codify by AAPC.
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 S09.90XA became effective on October 1, 2021.
Most of the commonly used codes for headache comes under categories G43 and G44 which can be found in chapter 6 (diseases of nervous system-code range G00-G99) in ICD-10 CM manual.
Migraine – Severe headache at one side of the head with light sensitivity and nausea.
Few examples below which are commonly found in medical record. Cluster headache – It is so called because it occurs in patterns or clusters. It is very severe, pain comes at one side of the head mostly around one eye. Migraine – Severe headache at one side of the head with light sensitivity and nausea.
Types of headache: Depending on the cause of headache it is divided as primary and secondary. Primary Head ache. This is due to any activity (physical or mental) which triggers the pain structures in head, not related to any underlying disease. Few examples below which are commonly found in medical record.
As per ICD coding guidelines routine signs and symptoms of a definitive diagnosis should not be coded separately. Hence if headache is mentioned in the medical record and if it is a common symptom of the diagnosis which we are coding (secondary headache),remember to avoid coding unspecified headache R51.9
Physician can diagnose the type of headache or the underlying cause depending on the area and severity of the pain and also from the history and physical exam. Based on these findings physician may do blood test, CT or MRI head, sinus X-ray, EEG or Spinal tap for further investigation. Coder needs to evaluate interpretation of these test results for more specific ICD code.
For both the above codes, migraine (category G43) is in excludes 2. So, as per the guideline we can code excludes 2 code also if documented in the medical record. But if we see G43 category codes, there is R51.9 in excludes 1. Hence migraine (G43) and R51.9 should not be coded together. You need to code only migraine as it is more specified.