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.