Traumatic brain injuries (TBIs) represent a significant public health concern, affecting individuals across all age groups and socioeconomic backgrounds. As frontline clinicians, emergency physicians play a crucial role not only in the diagnosis and management of TBI, but also in ensuring accurate documentation that supports vital epidemiological tracking and resource allocation. In collaboration with the Centers for Disease Control and Prevention (CDC), we aim to highlight the importance of precise TBI coding and provide practical guidance for optimizing your documentation practices.

A TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force. The severity of a TBI can range from mild, such as a concussion, to severe, resulting in prolonged unconsciousness or even death. TBIs can result from a variety of mechanisms, including falls, motor vehicle crashes, sports-related injuries, and assaults. The consequences of TBI can be wide-ranging, affecting cognitive, physical, and emotional functioning, with potential long-term effects on quality of life.

Significance of Accurate Coding

Although accurate coding is essential for appropriate billing and reimbursement, its significance extends beyond the financial realm. The International Classification of Diseases (ICD-10) codes assigned to patient encounters serve as the foundation for public health surveillance, research, and prevention efforts.

When TBI cases are consistently and accurately coded, we gain a clearer understanding of incidence and prevalence, allowing for monitoring trends in TBI rates over time and across different populations, identifying high-risk groups, and emerging patterns. Analyzing coded data enables researchers to identify risk factors that increase the risk of TBI, such as age, sex, socioeconomic status, and specific activities or occupations. Reliable TBI data informs decisions about where to allocate resources for prevention programs, treatment services, and rehabilitation facilities. Consistent and accurate coding allows evaluation of public health intervention efforts aimed at reducing TBI incidence and improving outcomes.

Unspecified Codes

A significant challenge in TBI surveillance is the overuse of unspecified ICD-10 codes, particularly S09.90—“Unspecified injury of head.” Although this code may seem appropriate when documentation lacks specific details, its broad nature obscures the true burden of TBI. As highlighted by the CDC, the S09.90 code encompasses a wide range of head injuries, from minor lacerations to severe TBIs, leading to an underestimation of TBI incidence. The Centers for Medicare and Medicaid Services (CMS) states that unspecified codes should only be used when there is insufficient information to assign a more specific code. However, this code is still commonly used in administrative billing claims data, even when documentation reflects a more specific diagnosis.