Effective October 1, 2010 a new code has been created to uniquely identify post-traumatic seizures (780.33).
A post-traumatic seizure (PTS) is an initial or recurrent seizure episode not attributable to another obvious cause after penetrating or nonpenetrating traumatic brain injury (TBI).
Seizures that occur shortly after a person suffers a brain injury may further damage the already vulnerable brain by decreasing the amount of oxygen available to the brain. The risk that a person will suffer PTS progressively decreases as time passes after the injury.
Early PTS has been found to increase the risk of post traumatic epilepsy (PTE). Seizures due to post-traumatic epilepsy are differentiated from post-traumatic (nonepileptic) seizures based on the etiology and timing of the seizure after trauma. A person with PTE can develop late seizures, occurring more than a week after the initial trauma. Late seizures are considered to be unprovoked, while early seizures (those occurring within a week of trauma) are considered to be provoked (direct result of the injury). A provoked seizure is one that results from a nonrecurring cause such as the immediate effects of trauma rather than a defect in the brain; it is not an indication of epilepsy.
The patient, a 16-year-old male, was hit by a car while inline skating and suffered a contusion to the cerebral cortex. While hospitalized, the patient suffered a post traumatic seizure lasting 3 minutes. Craniotomy was performed for decompression. How should this case be coded?
Assign code 851.00, Cortex (cerebral) contusion without mention of open intracranial wound, unspecified state of consciousness, as the principal diagnosis. Assign code 780.33, Post traumatic seizures, as an additional diagnosis. Assign codes E814.7, Motor vehicle traffic accident involving collision with pedestrian, Pedestrian; E849.5, Place of Occurrence, Street and highway; E006.0, Roller skating (inline) and skateboarding; and E000.8, Other external cause status, to describe the external cause, place of occurrence activity and status. In addition, assign code 01.24, Other craniotomy, for the procedure.