Mistakes In Coding Severe Traumatic Brain Injury

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Traumatic brain injury is often classified at the Emergency Department using the International Classification of Diseases (currently referred to as the ICD-9-CM). A recent study, however, found that the ICD-9-CM was only sensitive for accurately diagnosing two specific types of severe traumatic brain injury-skull fracture and intracranial hemorrhage.

The study also found that 1 out of 5 patients were not even diagnosed with a specific type of brain injury. Accurate coding is important for predicting treatment needs and outcome. One of the problems the researchers found in inaccurate coding was that many patients suffered from multiple types of brain injury. If a diagnosis only describes one specific part of the injury, there is a risk that important details related to other specific injuries would be lost. This is detrimental to both clinicians having to make treatment decisions, as well as the patients who could receive inaccurate discharge instructions.

Carroll CP, Cochran JA, Guse CE, & Wang MC. Are we underestimating the burden of TBI? Surveillance of severe TBI using CDC ICD-9-CM traumatic brain injury codes. Neurosurgery. (September 2012).