Traumatic Brain Injury PART NINE: Best Practice Guidelines for Coding-Video: TBI 9

Video Transcription

Video Summary

The webinar on Coding Traumatic Brain Injuries is part of a series covering trauma care for TBI patients, moderated by Kim Berry, with Robin Schrader as the speaker. Robin, the Trauma Registry Operations Manager at VCU Medical Center, has extensive experience and credentials in trauma registry and is currently pursuing further education.<br /><br />The webinar discusses best practices in coding TBIs, focusing on the types of TBI (mild, moderate, severe), their symptoms, causes (such as falls, MVCs, violence, sports), and complications. A detailed explanation is given on coding the injuries, specifically on loss of consciousness (LOC) and types of brain injuries like closed or open head injuries, non-traumatic TBIs, and diffuse axonal injury (DAI), emphasizing requirements such as immediate LOC, radiological evidence, and physician documentation to code DAIs.<br /><br />The speaker also covers common brain injuries such as concussions, skull fractures, and various types of brain bleeds. Specifics about coding rules in situations where imaging results are nonspecific or contradict, and using physician notes as authoritative, are provided. Practical advice is offered on reading the patient's behaviors in ER cases to help identify TBIs and approaches to differentiating traumatic from non-traumatic hemorrhages.<br /><br />Additionally, procedural coding for diagnosis and treatment is discussed, covering scans, ICP monitoring, and brain surgeries like craniotomies, craniectomies, and hematoma evacuations.<br /><br />The webinar concludes with a Q&A segment addressing GCS scoring for patients with cognitive limitations and the importance of using specific documentation to avoid over-coding injuries. Robin emphasizes validating and verifying head injury coding, particularly for TQIP participants to ensure data accuracy.

Keywords

Traumatic Brain Injuries

TBI coding

Kim Berry

Robin Schrader

Trauma Registry

VCU Medical Center

loss of consciousness

diffuse axonal injury

brain surgeries

GCS scoring