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.

The widespread use of the S09.90 code hampers TBI surveillance efforts and emergency department data. The CDC removed it from its TBI surveillance definition in 2016 to avoid overestimating this injury because of its broad nature.¹ This means that many people with a TBI are not being included in surveillance estimates, resulting in considerable undercounting of these injuries. Further, data on people who are more likely to visit an emergency department than a primary care office for TBI care, such as patients with public insurance and those who are Black or Hispanic, are more likely to get left out of data used for research and surveillance.²

Best Practices

To ensure accurate TBI coding and to contribute to improved surveillance efforts, consider following best practices. Use specific language about a TBI diagnosis in your documentation. Using the term “traumatic brain injury” without any other details will code to “unspecified intracranial injury.” Be as specific as possible noting whether there is a concussion alone or more serious injury such as traumatic cerebral edema or diffuse brain injury.

Editor’s Note
A common code seen in Texas, and an interesting cause of TBI, is W52.22, “struck by cow,” which I recently used for a patient who fell off a bull and got kicked in the head. —Dr. Cedric Dark

Appropriate details can go a long way in accurately coding TBIs and advancing TBI research and surveillance. Avoid vague terms like “head injury” or “closed head injury” without further specification. Note whether the patient experienced loss of consciousness (LOC), even if it was brief. The duration of LOC is also valuable information; absence of LOC does not rule out TBI.

Record any cognitive, physical, or emotional symptoms associated with the injury, such as headache, dizziness, memory problems, difficulty concentrating, or mood changes. Additional diagnoses with more specificity may include: S06.0x—concussion, S06.2x—diffuse traumatic brain injury, S06.3x—focal traumatic brain injury, S06.4x—epidural hemorrhage, S06.5x—subdural hemorrhage, S06.6X—subarachnoid hemorrhage.  Document how the injury occurred (e.g., fall from standing, motor vehicle collision) as this can provide valuable context for understanding the nature and severity of the TBI.

The CDC offers a wealth of resources on TBI, including coding guidance, diagnostic tools, and management strategies. The CDC website also includes an online training course, checklists (pediatric and adult patients), and patient discharge instruction videos based on the latest clinical recommendations.

By adopting best practices in documentation and coding, physicians can play a vital role in improving TBI surveillance, informing public health initiatives, and ultimately enhancing the lives of patients affected by TBI.

References

1. Daugherty J, Yuan K, Sarmiento K, Law R. Are there seasonal patterns for emergency department visits for head injuries in the USA? Findings from the National Electronic Injury Surveillance System-All Injury Program. Injury Prevention. 2024;30(1):46-52.
2. Peterson A, Gabella BA, Johnson J, et al. Multisite medical record review of emergency department visits for unspecified injury of head following the ICD-10-CM coding transition. Injury Prevention. 2021;27(Suppl 1):i13-i18.