Archive for August, 2018

TBI: Coding Traumatic Brain Injuries

Posted by Samantha Serfass on August 21, 2018 in Blog, General

TBI: Coding Traumatic Brain Injuries

The correct coding of Traumatic Brain Injury (TBI) can cause confusion… no pun intended. The coder needs to understand not only the definition of a Traumatic Brain Injury, but also must recognize the difference between coding a Personal History of TBI and reporting a residual condition or sequela, that is a result of a TBI.

The Centers for Disease Control and Prevention (CDC) defines TBI as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury.  Severity may range from mild to severe. Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the individual.   All TBI’s are serious injuries, as they are brain injuries.  Oftentimes, the brain can be left with areas that are irreversibly damaged. Each year, TBI’s contribute to a substantial number of deaths and cases of permanent disability. There are various types of residual effects that a person can exhibit after the acute phase of the injury has ended.

In ICD-10-CM the term “Late Effect” has been replaced with “Sequela”. A sequela is the residual effect after the acute phase of an illness or injury has ended.  There is no time limit for use of a sequela code. The code for the acute phase of the illness or injury that led to the sequela is never reported with a code for the sequela.

Coding of Sequela requires 2 codes:

The nature of the sequela is sequenced first, with the sequela codes sequenced second.

Additional guidelines for reporting sequela of injuries:

The code that describes the sequela is reported 1st, followed by the code for the specific injury with a 7th character “S”, to identify the condition as a sequela of the injury.  The “S” is added only to the injury code.



Patient experienced a fall down steps, with loss of consciousness, resulting in a traumatic subdural hemorrhage. Physician documents injury occurred 3 years ago.. There are no apparent sequela, late effect, or residual conditions.

Assign code:  Z87.20   Personal History of Traumatic Brain Injury


Same patient, but documentation supports patient has a mild cognitive impairment as a result of the previous TBI.

Assign Codes:  G31.84  Mild Cognitive Impairment, so stated

                           S06.5X9S  Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, Sequela.


Please note:

“Codes from categories Z85 through Z92 are used to indicate a personal history of a previous condition. When the condition mentioned is still present or still under treatment, or if a complication is present, a code from the series Z85 through Z92 is not assigned.”


Format and Conventions and Current Coding Practices for ICD-10-CM and ICD-10-PCS

Z Codes & External Cause of Morbidity Codes/Codes Representing Patient History, Status, or Problems

Healthcare RCM: Everyone’s Responsibility

Posted by Samantha Serfass on August 7, 2018 in Blog

Healthcare RCM: Everyone’s Responsibility

Emerging technologies now drive the transition and evolution of revenue cycle management. This is brought about by the pursuit hospitals and healthcare providers must focus on to not only improve financial system management, but to also identify hidden streams of revenue. Healthcare organizations are looking to implement newer technologies that will streamline processes, speed up insurance authorization, deliver new streams of income and minimize the time it takes to receive payment.


Improving Patient Workflow Automation

The importance of helping hospitals improve their patient workflows through automation and to accurately drop the bills on time is something healthcare technologist know all too well. Every point of patient contact, patient data collection, diagnosis and treatment, eligibility and verification are critical to the bottom line.

Although every healthcare facility may have a unique culture, whether full service or particular specialties, one thing that ties all healthcare systems together is the patients. The challenge for most facilities is the time it takes to capture patient clinical workflows and processes detailed enough to build a comprehensive and robust system. Unfortunately, developing a well-documented workflow takes multiple reiterations and can require hours of work.

Capturing accurate and efficient patient registration, admissions and eligibility, streamlining ER processes, collaborative and seamless transfers to/from healthcare facilities, enhancing efficiency and patient safety through the reduction of medication errors, to minimizing drug dosage and dispensing issues, and ultimately automating medical records management with secure accessibility –all  have major impacts on healthcare revenue management systems. One big challenge many facilities face is the lack of qualified skilled resources.


Coordination & Collaboration of Healthcare System

With increasing improvements throughout the years, many hospitals continually face the challenge of hiring and keeping qualified skilled resources through important projects. Yet, the even greater challenge comes after a productive project leadership team has been established, along with a clear vision and objectives.

Coordinating and communicating with all the respective stakeholders and areas of a hospital system takes preparation and consistency through planning. As we experience the changes in the revenue cycle system process, it no longer only impacts the traditional revenue cycle model. It impacts the entire patient workflow process, all invested departments, and the new advanced technology teams continuously working together to improve the revenue cycle management system.

Investing time to improve and change the quality of our healthcare resources is a must. One important example is frontline healthcare workers. It is critical that frontline healthcare workers understand the importance of improving the quality of patient care through gathering accurate patient information during the first encounter. Many times unskilled admission, registration and eligibility resources are hired to save money. While in the end, hours of work are spent correcting inaccurate patient information during charge capture, claims, coding, or remittance, which ultimately delays the bill drop.

Just like HIT security has becoming everyone’s business and responsibility, revenue cycle management has also become everyone’s responsibility. Whether you’re a clinician or administrator, working in admissions, registration and eligibility, operations, ambulatory, ER or IT, working together to improve the process and obtain accurate patient information is your responsibility.


Complexity of Revenue Cycle Management System

One thing is clear, the last 10-20 years have brought extensive changes in provider productivity and hospital internal revenue drivers. Regulatory changes, ICD-10 and continued mergers of revenue cycle systems have not only become the norm, but appear to be increasing every year. Hospital systems continue to invest time and money in order to gain knowledge and understanding of how new technologies can be implemented to increase their bottom line. Today, healthcare systems are looking for vendors who can provide end-to-end revenue cycle management that can solve the growing financial challenges they face each year.

There are several benefit to improving revenue cycle management such as streamlining patient workflow automation, improving productivity of departments and resources, and creating positive impacts on patient satisfaction.

By improving not only the quality of the patients experience, but educating and investing in the resources, hospital systems can successfully improve revenue cycle management. This allows for continued collaborations towards successfully finding new streams of revenue and increase the bottom line.


Nina De Los Santos, PMP

VP Operation Delivery at Excite Health Partners