AHA Coding Clinic® for ICD-9 - 2005 Issue 2; Ask the Editor

Traumatic Brain Injury (TBI) with Diffuse Axonal Injury (DAI)

The patient is a 37-year-old male who was involved in a motor vehicle accident. He was initially admitted to an acute care hospital for traumatic brain injury (TBI) with diffuse axonal injury (DAI) and shearing type injuries and was transferred to a long term care hospital (LTCH) for continued management of the TBI and neurological deficits. He was primarily admitted for continued treatment of the traumatic brain injury and was subsequently referred for a comprehensive rehabilitation program at the LTCH, including cognitive, physical and occupational therapy. The physician documented the patient’s discharge diagnoses as traumatic brain injury with diffuse axonal injury, disorders of concentration, decreased short term memory, difficulty with attention and maintaining awareness, impaired balance and gait and impaired activities of daily living. What are the correct code assignments for the LTCH admission? ...

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