EmailHead injury
Publication Date: September 2006
ICD 10 AM Edition: Fourth edition
Retired Date: 30/6/2010
Query Number: 2200
NCCH Query 2003 Patient admitted with head injury with haematoma to scalp states the following:
Question:
Initial query 12/07/04: ACS 1905 suggests that S09.9 Unspecified injury of head should be used when no more specific diagnosis is recorded. The coder interpreted the superficial injury (S008.5) to be a more specific diagnosis and therefore coded this as the principal diagnosis. It was agreed that head injury should be the principal diagnosis as they were probably admitted for observation of the head injury rather than the superficial injury. Could you please confirm that this is the correct way to code this scenario? Could the standard be updated to qualify what a more ‘specific diagnosis’ would be?
Resubmission 06/12/04: Further to your response NCCH Query ID Number 2003. Members of the committee were under the impression that the term 'head injury' S09.9 generally related to an internal (cranial) injury that could not be otherwise specified. The answer to our original query seems to indicate that a laceration to the head S01.88 could be interpreted as a 'head injury' and would be used in place of the S09.9. Was this answer related specifically to the record in question (i.e. documented as a minor head injury) or is this answer to be applied to all cases. That is, if there is documentation of a laceration and a 'head injury' only the laceration should be coded?
Answer:
Initial response 18/10/04: Thank you for the clinical records relevant to this query.
Documentation in the clinical record states:
-minor head injury
-small laceration and lump to right side of forehead
-superficial laceration to right forehead
-bandaid applied to laceration
The patient was a one year old child. Neurological observations were planned, but not conducted. The admission lasted only three hours and twenty minutes as the child's mother was ‘keen to go home and willing to observe’ the child.
For the case cited assign:
S01.88 'Open wound of other parts of head
'S09.9 'Unspecified injury of head' is an NOS (not otherwise specified) code. It should only be used when there is no other documented injury to the head.
The NCCH will consider amendments to ACS 1905 CLOSED HEAD INJURY/LOSS OF CONSCIOUSNESS/CONCUSSION to clarify the coding of 'head injury'.
Subsequent response 06/04/05: The NCCH supports the earlier advice given for this query. The initial response was related specifically to the case cited.
As per ACS 1905, where there is documentation in a clinical record of an injury to the head (for example, a laceration) and a nonspecific diagnosis of 'head injury', assign only a code for the laceration. The NCCH realises there are problems with the interpretation of ACS 1905 that may be causing discrepancies in code assignment between states/facilities. The NCCH will amend the standard for a future edition of ICD-10-AM to clarify this issue. Until further advice is issued, current coding practice should not be changed in order to maintain data consistency.(end of answer)
I have asked two clinicians (Director of ICU and Deputy Director of Emergency Department) about the diagnosis of ‘head injury’. They have confirmed that a head injury is a ‘state’, that is a condition in its own right. It would be diagnosed based on the presenting history and when ‘nothing is found’ it is not a condition that is ruled out. Tests can be used to demonstrate head injury but they are often not sensitive or precise enough because the change may be subtle, such as a change in maths ability or processing.
Therefore I query the NCCH decision not to code ‘head injury’ when that was one of the documented conditions for this patient. My understanding is that the code for ‘head injury’ should be assigned for documentation of a head injury and that ‘head injury’ should not be confused with an external injury to the head, such as a laceration or haematoma.
When a patient has a ‘head injury’ they are generally observed for signs of more significant intracranial injury. The response from NCCH states that “neurological observations were planned, but not conducted” but the patient was sent home to have continued observation by the parent, therefore I query if neurological observations were in fact conducted.
The duration of the admission (“only three hours and twenty minutes”) is irrelevant to what codes are assigned – this is an admission decision. The clinical documentation must determine what is coded.
What should be coded for the case cited?
Search Details: NCCH database #2003
Question:
Initial query 12/07/04: ACS 1905 suggests that S09.9 Unspecified injury of head should be used when no more specific diagnosis is recorded. The coder interpreted the superficial injury (S008.5) to be a more specific diagnosis and therefore coded this as the principal diagnosis. It was agreed that head injury should be the principal diagnosis as they were probably admitted for observation of the head injury rather than the superficial injury. Could you please confirm that this is the correct way to code this scenario? Could the standard be updated to qualify what a more ‘specific diagnosis’ would be?
Resubmission 06/12/04: Further to your response NCCH Query ID Number 2003. Members of the committee were under the impression that the term 'head injury' S09.9 generally related to an internal (cranial) injury that could not be otherwise specified. The answer to our original query seems to indicate that a laceration to the head S01.88 could be interpreted as a 'head injury' and would be used in place of the S09.9. Was this answer related specifically to the record in question (i.e. documented as a minor head injury) or is this answer to be applied to all cases. That is, if there is documentation of a laceration and a 'head injury' only the laceration should be coded?
Answer:
Initial response 18/10/04: Thank you for the clinical records relevant to this query.
Documentation in the clinical record states:
-minor head injury
-small laceration and lump to right side of forehead
-superficial laceration to right forehead
-bandaid applied to laceration
The patient was a one year old child. Neurological observations were planned, but not conducted. The admission lasted only three hours and twenty minutes as the child's mother was ‘keen to go home and willing to observe’ the child.
For the case cited assign:
S01.88 'Open wound of other parts of head
'S09.9 'Unspecified injury of head' is an NOS (not otherwise specified) code. It should only be used when there is no other documented injury to the head.
The NCCH will consider amendments to ACS 1905 CLOSED HEAD INJURY/LOSS OF CONSCIOUSNESS/CONCUSSION to clarify the coding of 'head injury'.
Subsequent response 06/04/05: The NCCH supports the earlier advice given for this query. The initial response was related specifically to the case cited.
As per ACS 1905, where there is documentation in a clinical record of an injury to the head (for example, a laceration) and a nonspecific diagnosis of 'head injury', assign only a code for the laceration. The NCCH realises there are problems with the interpretation of ACS 1905 that may be causing discrepancies in code assignment between states/facilities. The NCCH will amend the standard for a future edition of ICD-10-AM to clarify this issue. Until further advice is issued, current coding practice should not be changed in order to maintain data consistency.(end of answer)
I have asked two clinicians (Director of ICU and Deputy Director of Emergency Department) about the diagnosis of ‘head injury’. They have confirmed that a head injury is a ‘state’, that is a condition in its own right. It would be diagnosed based on the presenting history and when ‘nothing is found’ it is not a condition that is ruled out. Tests can be used to demonstrate head injury but they are often not sensitive or precise enough because the change may be subtle, such as a change in maths ability or processing.
Therefore I query the NCCH decision not to code ‘head injury’ when that was one of the documented conditions for this patient. My understanding is that the code for ‘head injury’ should be assigned for documentation of a head injury and that ‘head injury’ should not be confused with an external injury to the head, such as a laceration or haematoma.
When a patient has a ‘head injury’ they are generally observed for signs of more significant intracranial injury. The response from NCCH states that “neurological observations were planned, but not conducted” but the patient was sent home to have continued observation by the parent, therefore I query if neurological observations were in fact conducted.
The duration of the admission (“only three hours and twenty minutes”) is irrelevant to what codes are assigned – this is an admission decision. The clinical documentation must determine what is coded.
What should be coded for the case cited?
Search Details: NCCH database #2003
Response
This query was referred to the NCCH who provided the following response:
"The coding of 'head injury' has caused considerable discussion at the NCCH. We agree with the advice that a 'head injury' is a state or 'condition' in its own right. However, this clinical concept is not well dealt with in ICD-10-AM.
The two issues of concern are:
1. The interpretation of ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion with regards to 'a more specific diagnosis' for the head injury.
2. The lack of an appropriate code for 'head injury' within ICD-10-AM (S09.9 Unspecified injury of head is non-specific and is used for 'any other site of head' including injuries to chin, brow, forehead, lip, mouth etc.)
We recognise that the previous response regarding the coding of a laceration as a 'more specific diagnosis' may not be entirely appropriate. As stated previously we are undertaking to review ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion regarding the use of S09.9 Unspecified injury of head and to clarify the phrase 'more specific diagnosis'.
In the meantime, we would strongly recommend that each site continues to apply the standard in an agreed and consistent manner (i.e. continue to code as you have done previously) until further advice is received."
The VICC advises that when there is documentation of closed head injury and other injury to head, for example, open wound that these two conditions should be coded separately. The principal diagnosis will be determined by ACS 0001 Principal diagnosis.
"The coding of 'head injury' has caused considerable discussion at the NCCH. We agree with the advice that a 'head injury' is a state or 'condition' in its own right. However, this clinical concept is not well dealt with in ICD-10-AM.
The two issues of concern are:
1. The interpretation of ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion with regards to 'a more specific diagnosis' for the head injury.
2. The lack of an appropriate code for 'head injury' within ICD-10-AM (S09.9 Unspecified injury of head is non-specific and is used for 'any other site of head' including injuries to chin, brow, forehead, lip, mouth etc.)
We recognise that the previous response regarding the coding of a laceration as a 'more specific diagnosis' may not be entirely appropriate. As stated previously we are undertaking to review ACS 1905 Closed Head Injury/Loss of Consciousness/Concussion regarding the use of S09.9 Unspecified injury of head and to clarify the phrase 'more specific diagnosis'.
In the meantime, we would strongly recommend that each site continues to apply the standard in an agreed and consistent manner (i.e. continue to code as you have done previously) until further advice is received."
The VICC advises that when there is documentation of closed head injury and other injury to head, for example, open wound that these two conditions should be coded separately. The principal diagnosis will be determined by ACS 0001 Principal diagnosis.
