Find information on diagnosing a history of concussion, including clinical documentation requirements, ICD-10 codes (S06.0X), post-concussion syndrome (PCS) diagnosis, and return-to-play guidelines. Learn about concussion assessment tools, neuropsychological testing, and differential diagnosis considerations for healthcare professionals involved in concussion management and medical coding. This resource provides insights into accurately documenting and coding a history of concussion for optimal patient care and billing practices.
Also known as
Intracranial injury
Codes for concussion and traumatic brain injury.
Postconcussional syndrome
Lingering symptoms after a concussion.
Disorientation, unspecified
May be relevant if concussion caused disorientation.
Headache, unspecified
May be used if headache is a residual effect.
Follow this step-by-step guide to choose the correct ICD-10 code.
Current concussion symptoms?
Yes
Do NOT code history of concussion. Code the current concussion diagnosis (e.g., S06.0X).
No
Documented history of concussion?
When to use each related code
| Description |
|---|
| History of concussion |
| Postconcussion syndrome |
| Current concussion |
Coding concussion without specifying current or history creates ambiguity and potential downcoding risk impacting reimbursement.
Incorrectly coding history of concussion as late effect when no residual deficits exist leads to overcoding and compliance issues.
Lack of proper documentation supporting concussion history hinders accurate coding, causing claim denials and audit vulnerabilities.
Patient presents with a history of concussion. The patient reports experiencing a previous head injury resulting in a concussion, diagnosed on (date of prior diagnosis) following (mechanism of injury, e.g., a motor vehicle accident, sports injury, fall). Symptoms at the time of the initial injury included (list initial symptoms, e.g., headache, dizziness, nausea, vomiting, amnesia, loss of consciousness). Duration of loss of consciousness, if any, was (duration). Post-concussion symptoms, if any, included (list ongoing symptoms, e.g., persistent headache, difficulty concentrating, memory problems, sleep disturbances, light sensitivity, noise sensitivity, irritability, anxiety, depression). The patient reports that these symptoms lasted for (duration). Current symptoms, if any, related to the history of concussion include (list current symptoms). Neurological examination reveals (describe findings, e.g., normal cranial nerves, normal motor strength and coordination, no focal neurological deficits). Mental status examination is (describe findings, e.g., alert and oriented to person, place, and time). Assessment: History of concussion with (mention current status, e.g., resolved symptoms, persistent post-concussion syndrome). Differential diagnosis includes (list relevant differentials, e.g., post-traumatic headache, migraine, anxiety disorder). Plan: Patient education provided regarding concussion management, including (mention specific advice, e.g., symptom monitoring, return to activity guidelines, cognitive rest). Follow-up recommended (mention frequency and purpose, e.g., as needed for persistent symptoms, neuropsychological testing if indicated). ICD-10 code: S06.0X (specify appropriate code).