Traumatic Brain Injury PART NINE: Best Practice Guidelines for Coding-Handout: TBI NINE

Handout: TBI NINE

Pdf Summary

The document "Best Practice Guidelines for Coding TBI" by Robin L. Schrader from the VCU Medical Center provides comprehensive guidance on coding practices related to traumatic brain injuries (TBI). It is part of an educational statement by the Trauma Center Association of America, designed for registered nursing and medical professionals to enhance understanding in diagnosing and documenting TBI cases. The document is approved by the California Board of Registered Nursing for educational credits.<br /><br />The guidelines cover several critical areas:<br /><br />1. <strong>Types of TBI</strong>: Describes mild, moderate, and severe TBIs, their symptoms, and Diagnosis Coding strategies. Mild concussions generally involve brief loss of consciousness and a Glasgow Coma Scale (GCS) of 13-15. Moderate TBIs show consciousness loss for more than 30 minutes, with a GCS of 9-12. Severe TBIs result in loss for a full day and possess noticeable CT/MRI changes with a GCS of 3-8.<br /><br />2. <strong>Injury Mechanisms and Causes</strong>: Discusses the primary causes including falls, motor vehicle accidents, and assaults, with older adults and children being more susceptible to falls. It also highlights symptoms varying based on severity, including unconsciousness, memory issues, and seizures.<br /><br />3. <strong>Diagnosis Coding</strong>: Covers distinct coding rules for different TBI types, relying on documented loss of consciousness, imaging results, and clinician reports to ensure accurate ICD-10 coding. This section outlines specifics like coding for Diffuse Axonal Injury, brain bleeds, and cerebral edema.<br /><br />4. <strong>Procedural Codes and Treatment</strong>: Provides codes for diagnostic and treatment procedures including CT/MRI scans, intracranial pressure monitors, craniotomies, and brain decompression methods.<br /><br />5. <strong>Common Complications</strong>: Highlights complications such as permanent brain damage, seizures, CTE, and various behavioral/mood alterations post-injury.<br /><br />The document includes quiz questions to assess the reader's comprehension of proper coding practices. Robin L. Schrader provides contact information for further questions, ensuring practitioners can access support when needed for TBI coding.

Keywords

Traumatic Brain Injury

TBI Coding

Diagnosis Coding

ICD-10

Glasgow Coma Scale

CT/MRI

Diffuse Axonal Injury

Craniotomy

Seizures

Educational Credits