ICD-10 Codes for Traumatic Brain Injury (TBI)

About 1.7 million cases of TBI occur in the U.S. every year, according to the American Association of Neurological Surgeons (AANS).

1. ICD-10 Codes for
Traumatic Brain Injury
About 1.7 million cases of TBI occur in the U.S. every year, according to the
American Association of Neurological Surgeons (AANS).
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United Sates

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Traumatic brain injury (TBI) is defined as a blow to the head or a
penetrating head injury that disrupts the normal function of the brain.
According to the American Association of Neurological Surgeons (AANS),
about 1.7 million cases of TBI occur in the U. S. every year, with
approximately 5.3 million people living with a disability caused by TBI. The
CDC reports that in 2014, an average of 155 people in the United States
died each day from injuries that include a TBI. As physicians focus on
providing care, they can rely on coding and medical billing services to
report the appropriate code to report diagnosis and treatment.

March is Brain Injury Awareness Month and the theme for 2018-2020 is
“Change Your Mind.” The campaign provides a platform for educating people
about incidence of brain injury and the needs of people with brain injuries
and how to support their families.

TBI – Causes and Types

TBI usually occurs when the head or body receives a violent blow or jolt or
an object pierces the skull and enters brain tissue. Falls, motor vehicle
accidents and being struck by or against an object are the leading causes of
TBI. TBI disrupts the normal function of the brain.

Depending on the extent of damage, TBI can be mild, moderate or severe.
Mild cases may affect the brain cells temporarily and cause a brief change in
mental state or consciousness. Mild TBIs or concussions are the most
common type. Moderate to severe TBI may include any of the signs and
symptoms of mild injury, as well as bruising, torn tissues, bleeding and
other physical damage to the brain, which may appear within a few hours to

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days following the head injury. Severe injuries can result in extended
periods of unconsciousness, coma or death.

Diagnosis

Patients with traumatic brain injuries usually need detailed and quick
evaluation in the emergency room. This may involve the following:
- Cardiac and pulmonary function followed by an exam of the whole
body.
- Systematic neurological examination to reveal evidence of brain
injury..
- Radiological tests – While plain x-ray is usually enough to evaluate
patients with only mild neurological dysfunction, brain imaging with
CAT scan, MRI, SPECT and PET scan are necessary to detect crucial
lesions such as the presence of blood and fractures.
- Cognitive evaluation and formal neuropsychological testing. The
Glasgow Coma Scale helps medical personnel to assess the initial
severity of a brain injury by checking a person's level of consciousness
(such as the ability to follow directions and move their eyes and
limbs).
- Evaluations by physical, occupational and speech therapists can help
shed light on the specific concerns.

ICD-10 Codes for Traumatic Brain Injury

The ICD codes for TBI are as follows:
S02.0 Fracture of vault of skull
S02.1 Fracture of base of skull
S02.7-S02.9 Multiple fractures involving skull and facial bones

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Fractures of other skull and facial bones
Fracture of skull and facial bones, part unspecified
S04.0-S04.9 Injury of cranial nerves
S06.0-S06.9 Concussion
Traumatic cerebral oedema
Diffuse brain injury
Focal brain injury
Epidural haemorrhage
Traumatic subdural haemorrhage
Traumatic subarachnoid haemorrhage
Intracranial injury with prolonged coma
Other intracranial injuries
Intracranial injury, unspecified
S07.1 Crushing injury of skull
S07.8 Crushing injury of other parts of head
S07.9 Crushing injury of head, part unspecified
S09.7-S09.9 Multiple injuries of head
Other specified injuries of head
Unspecified injury of head
T02.0 Fractures involving head with neck
T04.0 Crushing injuries involving head with neck
T06.0 Injuries of brain and cranial nerves with injuries of nerves and spinal
cord at neck level

Points to Note: Here is some important guidance on ICD-10 coding for TBI
from a report published by the National Academy of Sciences in 2019
(https://www.ncbi.nlm.nih.gov/books/NBK542610):

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o ICD-10 codes are assigned based on loss of consciousness (LOC) time
after the injury. To ensure the most accurate and appropriate level of
coding, documentation must clearly indicate if there was an LOC due
to the injury and the duration of the LOC. If documentation does not
clearly define the LOC then unspecified state of consciousness must be
coded.
o Code Z87.820 Personal history of traumatic brain injury is usually used
identify a personal history of injury with or without a confirmed
diagnosis.
o Code Z13.850 should be used if TBI screening occurs at a visit,
whether or not the screening is positive. A positive screen does not
denote a TBI diagnosis. A TBI ICD 10 code should be reported only for
the encounter at which the diagnosis is made.
o Clinical documentation must clearly indicate that the encounter coded
– initial (A), subsequent (D) or sequel (S).

The Centers for Disease Control states that everyone is at risk for TBI,
especially children and older adults. Many Americans are living with
permanent disabilities caused by TBI that includes a loss of independence
and lack of direction. While it may not be possible to prevent all traumatic
brain injuries, supporting the March Change Your Mind campaign can help
create an ongoing dialogue to raise awareness about the risks associated
with brain injury and its incidence, and improve support for people with
brain injuries and their families.

Experienced medical billing service providers have expert coders on board
who can help physicians report the appropriate codes in the billing process.
This is important to ensure error -free claims and appropriate
reimbursement.