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.
“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