tci ED Coding & Reimbursement Alert - 2004 Issue 12

You Be the Coder: Watch Out for Physician Variation in Head Injury Documentation

Question: Which ICD-9 code should we report for a closed head injury""? There was no loss of consciousness. Because the physician specified the head injury as closed we were going to report 854.01 instead of 959.01.Arkansas Subscriber  Answer: From a coding point of view 959.01 (Head injury unspecified) would be appropriate for a more minor injury involving a contusion of the head in which the patient has swelling or pain in the skin scalp or other non-bony soft tissues of the head. The exclusion note for this code refers to various other codes for...

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