ICD-10 Coding for History of Concussion(Z87.820, S06.0X-, G93.4)
Complete ICD-10-CM coding and documentation guide for History of Concussion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Concussion
Z87.820Primary Range
Personal history of traumatic brain injury
Used for documenting a resolved concussion that is relevant to current care.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z87.820 | Personal history of traumatic brain injury | Use when the concussion is resolved and relevant to current care. |
|
| S06.0X- | Concussion | Use for active concussion management. |
|
| G93.4 | Post-concussion syndrome | Use for persistent symptoms following a concussion. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for history of concussion
Essential facts and insights about History of Concussion
Primary ICD-10-CM Codes for history of concussion
Decision Criteria
clinical Criteria
- No active symptoms present
documentation Criteria
- Documented resolution of concussion
Clinical Validation Requirements
- Documented prior diagnosis of concussion
- Resolution of symptoms
Code-Specific Risks
- Incorrectly using for active symptoms
Coding Notes
- Ensure documentation specifies resolved status and any relevant historical details.
S06.0X- - Concussion
Use for active concussion management.
Applicable To
- Active concussion management
Excludes
- Resolved concussion (Z87.820)
Clinical Validation Requirements
- Presence of active symptoms
- Ongoing treatment
Coding Notes
Ensure correct 7th character is used for encounter type.
G93.4 - Post-concussion syndrome
Use for persistent symptoms following a concussion.
Applicable To
- Persistent symptoms post-concussion
Excludes
- Resolved concussion (Z87.820)
Clinical Validation Requirements
- Symptoms persisting >3 months
Coding Notes
Document specific symptoms and duration.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fall on playground
W09.0XXADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Concussion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z87.820.
Impact
Clinical: Inaccurate patient history, Regulatory: Non-compliance with documentation standards, Financial: Potential billing issues
Mitigation Strategy
Always document resolution date, Review patient history for completeness
Impact
Reimbursement: May lead to incorrect billing and denials, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records
Mitigation Strategy
Use Z87.820 for resolved cases
Impact
Using active concussion codes for resolved cases
Mitigation Strategy
Regular training on code differentiation
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Concussion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Concussion
Use these documentation templates to ensure complete and accurate documentation for History of Concussion. These templates include all required elements for proper coding and billing.
Routine follow-up for resolved concussion
Specialty: Primary CareRequired Elements
- Date of original concussion
- Mechanism of injury
- Resolution of symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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