A: You may use codes 161002.2 through 161006.3 when the MD confirms “positive LOC”. This does not have to be witnessed by the MD. If they believe there was LOC and document it, we may code it. We do not need to have the word “concussion” in the chart in order to code LOC. If the EMS agency notes LOC, the physician must corroborate this finding in the medical record for you to code it in AIS.
This was answered in the monthly questions (January 2014) differently. It states not to code the LOC in conjunction with an anatomic brain injury.
Q: If there is a cerebral hemorrhage NFS and LOC of some duration, how can this be coded? May we use concussive injury codes in addition to the hemorrhage code?
A: Do not code coma in addition to the hemorrhage. When there is an anatomic brain injury the concussive codes are not used additionally. If the only injury is a skull fracture (no damage to the brain substance) and there is documented LOC you may use the concussive injury codes additionally.
I would disagree with this answer: I was taught not to use concussion codes, including 161002.2 through 161006.3, if the patient has intracranial injuries. LOC should be indicated in description only. I use these concussion codes if there is no obvious injury seen on contemporary radiology reports. Historically, word “Concussion” was used for those injuries that don’t have anatomical damage, but have disturbances in brain function, reporting symptoms such as confusion, lethargy, memory problems and more.
If an injury is diagnosed as “subacute”, is the injury coded as an acute injury or NFS injury?
What will be the code if there is Concussion with LOC but the duration of LOC was not specified?
Thanks.
We have a patient that sustained a GSW to the face-technically his injuries meet the Lefort II fractures however I am not sure since the parts of the Lefort II fracture are completely gone. how would you code the following?
Bilateral maxillary and palatal comminuted, LeFort II “open”
Bilateral nondisplaced orbital fractures
Anterior septal and premaxillary alveolar fx with segmental aveolar loss
Complex mandibular fx with segmental loss
Complex facial soft tissue injury w/ loss of lips and right nasal floor
Q: What is the correct code for a sigmoid mesocolon tearing?