Post traumatic brain injury icd 9


A forceful hit or jolt to the head or body frequently causes traumatic brain damage. Traumatic brain injury can also be caused by an object that passes through brain tissue, such as a gunshot or a fractured piece of skull.

A mild traumatic brain injury can cause temporary damage to your brain cells. Bruising, torn tissues, hemorrhage, and other physical damage to the brain can occur with more acute traumatic brain injury. Long-term problems or mortality can occur as a result of these injuries.

TBI, also known as acquired brain damage, head injury, or brain injury, results in significant impairment and fatality. It occurs when the brain is damaged and normal brain function is disrupted as a result of a rapid trauma. TBI has the potential to have significant physical, psychological, cognitive, emotional, and social consequences.

According to the US Centers for Disease Control and Prevention (CDC), TBI-related emergency department visits, hospitalizations, and deaths occurred in the United States in 2013.

Traumatic brain injury icd 9

ICD-9-CM category 854, intracranial damage of other and unidentified nature, is assigned to BI without further explanation. If the intracranial injury mentions an open intracranial wound, the fourth digit subcategory identifies it.

Assign code 959.01 if the TBI is simply documented as a closed head injury with no further description. When a person takes a forceful hit to the head from striking an object, but the object does not crack the skull, it is called a closed head injury. If there was a loss of consciousness as a result of a closed head injury or a TBI, instead of 959.01 or a code from category 854, assign a code from category 850, Concussion.

If a TBI or closed head injury is accompanied by other injuries, a more specific code should be assigned as follows:

  • Category 851, laceration and contusion of the brain;
  • Category 852, post-injury subarachnoid, subdural, and extradural hemorrhage; or
  • Category 853, unidentified intracranial bleeding as a result of an injury.

For categories 851 to 854, a fifth digit subclassification is necessary to specify any loss of consciousness and the duration:


  • 0. Condition of consciousness that has not been defined;
  • 1. if there is no loss of consciousness
  • 2. With a short loss of consciousness (less than an hour);
  • 3. With a brief loss of consciousness (one to 24 hours);
  • 4. With protracted loss of consciousness (more than 24 hours) and restoration to pre-existing conscious state;
  • 5. With a protracted loss of consciousness (more than 24 hours) with no restoration to a previous level of consciousness. (This fifth digit is used to indicate when a patient is unconscious and dies before regaining consciousness, regardless of how long the patient was unconscious.)
  • 6. With an undefined period of unconsciousness; and
  • 9. With an undetermined concussion.


A concussion is caused by a hit to the head that causes a temporary or permanent change in consciousness, which may be accompanied by forgetfulness, dizziness, nausea, and a weak pulse. Memory, judgment, reflexes, speech, balance, and coordination may all be affected by a concussion. Consciousness loss is not usually associated with concussions.

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Concussions that aren’t further classified fall within category 850. The fourth digit subcategory will indicate whether or not there was any loss of consciousness and how long it lasted. If there is a brain contusion, laceration, or hemorrhage, the concussion is divided into categories 851 to 853. A code from category 850 is never allocated to a code from 851 to 853. When a brain damage cannot be classified into categories 850 to 853, category 854 is used. A concussion is a closed head injury that is categorized to the proper code in category 850. “A code from category 854, Intracranial injury of other and unspecified kind, or code 959.01, Head injury, unspecified, is unsuitable when the head injury is stated as concussion” (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, page 10). Concussion patients usually recover entirely in 24 to 48 hours.

Mild TBI and Concussion Symptoms

Some mild TBI and concussion symptoms may show immediately, while others may take hours or days to appear. Symptoms of a moderate TBI or concussion usually improve over time, and most patients feel better within a few weeks.


Mild TBI and concussion symptoms might influence how you feel, think, act, and sleep.

Mild TBI and concussion symptoms vary from person to person. Symptoms may change as you get better. Earlier on, you might have had headaches and felt ill to your stomach. You may find that you are more emotional than normal or that you are having difficulties sleeping a week or two following your accident.

Traumatic brain injury (TBI)

Mild traumatic brain injury can cause the following signs and symptoms:

Physical signs and symptoms

  • Headache
  • Vomiting or nausea
  • Drowsiness or fatigue
  • Speech difficulties
  • Dizziness or a sense of being off balance

Symptoms of the Sensory

  • Blurry vision, ringing in the ears, a terrible taste in the mouth, or alterations in the ability to smell are all examples of sensory issues.
  • Light or sound sensitivity

Symptoms of cognition, behavior, or mental health

    • For a few seconds to a few minutes, you may lose consciousness.
    • There will be no loss of consciousness, but you will feel dizzy, confused, or disoriented.
    • Problems with memory or attention

  • Mood swings or fluctuations in mood
  • Feeling down or anxious?
  • Sleeping problems
  • Getting more sleep than normal

Traumatic brain injuries range from mild to severe.

Any of the signs and symptoms of mild injury, as well as these symptoms that may arise within the first hours to days following a head injury, can occur in moderate to severe traumatic brain injuries:

Physical signs and symptoms

  • The loss of consciousness might last anywhere from a few minutes to several hours.
  • Headache that doesn’t go away or becomes worse
  • Vomiting or nausea on a regular basis
  • Seizures or convulsions
  • Dilation of one or both of the eyes’ pupils
  • Fluids draining from the nose or ears are clear.
  • Inability to wake up from a deep slumber
  • Numbness or tingling in the fingers and toes
  • Coordination problems

Symptoms of the mind or intellect

  • Confusion abounds.
  • Irritability, combativeness, or other atypical behavior
  • Speech slurred
  • Consciousness abnormalities such as coma

Symptoms in children

Headaches, sensory issues, disorientation, and other symptoms may be difficult for infants and young children with brain injuries to communicate. You may notice the following in a youngster who has had a traumatic brain injury:

  • Changes in the way you eat or how you nurse
  • Irritability that is unusual or common
  • Crying that won’t stop and an inability to be consoled
  • Changes in attentional capacity
  • Sleeping patterns have changed.
  • Seizures
  • A sad or gloomy state of mind
  • Drowsiness
  • Loss of enthusiasm for previously enjoyed objects or activities

When should you see a doctor?

If you or your child has received a hit to the head or body that concerns you or produces behavioral problems, consult your doctor right away. If you have any indications or symptoms of traumatic brain injury after a recent blow or other severe injury to the head, get emergency medical attention.




A clinician evaluates a patient’s ability to follow instructions such as blinking his or her eyes or moving his or her extremities to diagnose a TBI. The doctor may also order X-rays or a CT scan to see if the TBI is a brain hemorrhage, hematoma, contused (bruised) brain tissue, or brain tissue swelling.


Although there is little that can be done to cure the trauma-induced brain damage, treatment focuses on preventing subsequent damage. Ensure optimal oxygen supply to the brain, maintain enough blood flow, and manage blood pressure are all goals of treatment.

The hemorrhage or hematoma in some TBIs requires surgery to remove or heal.

The implementation of the Official Coding Guidelines for inpatient care, as well as physician documentation in the medical record, are used to code and sequence TBI. To guarantee comprehensive and correct coding, consult specialized AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references.

Post traumatic brain injury icd 9

Post traumatic brain injury icd 9

Post traumatic brain injury icd 9

Mayo Clinic

Post traumatic brain injury icd 9