Find information on Post-Concussion Syndrome diagnosis, including clinical documentation, medical coding, and healthcare resources. Learn about common PCS symptoms, ICD-10 codes for concussion and post-concussion disorders, and best practices for healthcare professionals managing patients with persistent post-traumatic symptoms. Explore resources for accurate diagnosis and treatment of post-concussion syndrome.
Also known as
Postconcussion syndrome
Lingering symptoms after a head injury.
Intracranial injury
Injury to the brain, often a precursor to PCS.
Other reactions to severe stress
May include emotional or behavioral changes after trauma.
Headache
A common symptom of post-concussion syndrome.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the PCS diagnosed after head injury?
Yes
Symptoms within 4 weeks of injury?
No
Do NOT code PCS. Evaluate for alternate diagnosis.
When to use each related code
| Description |
|---|
| Symptoms persist after a concussion. |
| Acute head injury with loss of consciousness. |
| Cognitive impairment after brain injury. |
Coding PCS without sufficient documentation of persistent symptoms after the initial injury leading to unspecified codes and lost revenue.
PCS symptoms overlap with other conditions, leading to inaccurate coding, potential overcoding, and compliance risks if documentation lacks specificity.
Inaccurate coding of PCS duration (acute vs. chronic) impacting medical necessity reviews, reimbursement, and quality reporting accuracy.
Patient presents with persistent symptoms consistent with post-concussion syndrome (PCS) following a documented mild traumatic brain injury (mTBI) or concussion. The initial injury occurred on [Date of injury] and involved [Mechanism of injury]. Current symptoms, which began [Symptom onset timeframe] post-injury, include [List specific symptoms e.g., headache, dizziness, fatigue, memory problems, difficulty concentrating, irritability, sleep disturbances, sensitivity to light and noise, blurred vision]. These symptoms significantly impact the patient's [Specify areas of impact e.g., daily activities, work performance, academic performance, social interactions]. The patient reports [Symptom frequency and duration]. Neurological examination reveals [Specific findings e.g., normal neurological exam, mild cognitive impairment on bedside testing, balance difficulties]. Diagnostic considerations include ruling out other potential causes for the reported symptoms such as cervicogenic headache, vestibular disorders, depression, anxiety, and post-traumatic stress disorder (PTSD). Based on the patient's history, symptom presentation, and clinical findings, the diagnosis of post-concussion syndrome is established. The patient was educated about the typical course and prognosis of PCS. A multidisciplinary treatment plan was discussed, focusing on symptom management and includes [Specify treatment modalities e.g., cognitive behavioral therapy (CBT), vestibular rehabilitation therapy (VRT), occupational therapy, medication management for headache, sleep disturbance, or mood changes]. Referral to [Specify referrals e.g., neuropsychology, neurology, ophthalmology, physical therapy] is recommended. Follow-up is scheduled for [Date of follow up] to monitor symptom progression and adjust the treatment plan as needed. Current ICD-10 code: F07.81.