Another presentation that ranks in the top ten diagnosis codes for the emergency department and processed by web2pro is head injury (ICD-9 code 959.01 – head injury unspecified, which excludes concussion, concussion with head injury (850.1 – 850.9), head injury NOS with loss of consciousness (LOC) (850.1 – 850.5), and specified intracranial injury (850.0 – 854.1)). Head injury unspecified (959.01), at 1.1% of the total annual case presentations, ranked number eight, being coded 46,184 times.

Head trauma or injury has caused more deaths and disability than any other neurologic condition before the age of 50 and occurs in greater than 70% of accidents, which are the leading cause of death in men and boys less than 35 years old. Mortality from severe injury approaches 50% and is only modestly reduced by treatment.

Head trauma or injury is considered severe when any of the following conditions are present after the injury:

  • Blood or clear fluid coming from the ears or nose
  • Slurred speech
  • Unconsciousness
  • Confusion
  • Vomiting
  • Dizziness or drowsiness
  • Unequal pupil size or blurred or double vision.

If any of these conditions are present, it’s time to seek immediate medical attention.

Typically, the treatment for head injuries is initial resuscitation of a patient to prevent any hypoxia and hypotension. The combination of hypoxia and hypotension can increase the mortality rate than if neither of those factors is present. Once a patient is stabilized, evaluation of neurological status should begin. This is typically done after a Glasgow Coma Scale which provides a classification system for patients with head injuries, but does not substitute for a neurological exam. After a thorough neurological examination is conducted, a CT of the head would be obtained to help determine the next step(s).

The ICD code that will be assigned to a head trauma or injury will be dependent on the type of injury and associated symptoms a person presents with in the emergency department and the type of treatment that is provided. As stated above, the head injury can be with associated signs and symptoms and the physician’s documentation should reflect the type of injury and symptoms that are present in order to assign the most appropriate ICD code.

The current ICD-9 code book describes the different types of injury and with associated symptoms in different codes under Chapter 17, Injury and Poisoning, under section Certain Traumatic Complications and Unspecified Injuries (Code 959.01) and section Intracranial Injury, Excluding Those with Skull Fractures (Code range 850-854)

ICD-10 contains the head injury codes in Chapter 19, Injury and poisoning and Certain Other Consequences of External Causes, (S00 – S09).

There is a one to one crosswalk for head injury unspecified, and there are few other types of head injury codes that are assigned when certain types of symptoms are identified, such as concussion which is categorized by transient post-traumatic loss of awareness or memory, lasting from seconds to minutes. Head injury could also be associated with loss of consciousness.

The table below describes some of these codes from ICD-9 to ICD-10.

ATC EMS Head Injury Code

As you can see there are a good number of ICD-10 codes for head injury and injury with other symptoms – and this is only a small example of those in both ICD-9 and ICD-10 books. It is imperative that the provider document exactly what the examination and the diagnostic studies’ findings are, if any, to determine the exact course of action for the condition presented or defined after study and to assign the most appropriate codes from ICD-9 or ICD-10.

This commentary is a summary prepared by web2pro’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of emergency medicine and emergency medical

services. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association (“AMA”). The AMA is the owner of all copyright, trademark and other rights to CPT® and its updates.

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About the author

Robert Bunting, CPC, CPC-H, CHC, CEDC, CEMC, CAC is Compliance Director – Emergency Medicine, web2pro Business Performance Services.