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Coding tip of the week: How do I code residual effects from a traumatic brain injury?

January 11, 2012

I hope you’re having a nice week, dear readers! Here is this week’s coding tip, brought to you by Pathway Health Services.

Q:  How do I code residual effects from a traumatic brain injury where the initial trauma occurred long ago but we are still dealing with the sequelae such as gait abnormality, confusion, memory loss or seizures?

A:  What you describe would be called late effects of a traumatic brain injury.  These codes are in the 907 family.  The entire section 905 thru 909 deals with late effects of injuries.  One caution – unlike late effects of CVA (438 codes) where the late effect code comes first followed by additional codes to further describe the late effects – late effects of injury codes are done exactly opposite.  First list codes that describe the late effect (eg gait abnormality, memory loss) then list the 907.XX code.

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