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Breaking the Code: ICD-9-Clinical Modification Diagnosis Coding for Traumatic Brain Injury

The Defense and Veterans Brain Injury Center (DVBIC) reports an increase in unspecified (i.e., where the specific cause is not known) traumatic brain injuries (TBIs) in Defense Department numbers worldwide over the past two quarters. All TBIs are to be documented or classified to a code from ICD-9-Clinical Modification (CM). Proper coding provides a detailed picture of a patient population. It also contributes to quality outcomes and standards of care, permits correct reimbursements for clinical services and helps anticipate demand for future services. Accurate TBI coding is essential for these reasons.

Medical coding professionals consider TBI coding to be “specialty” coding. While all certified coders can code TBIs, most lack experience and clinical knowledge to code TBIs without guidance from coding specialists and clinical colleagues. Special rules apply to coding brain injuries in the Defense Department. Appendix G of the Military Health System Coding Guidance: Professional Services and Specialty Coding Guidelines Version 3.6 contains rules that apply to coding brain injuries for both deployed and non-deployed settings. These rules take precedence over any other coding guidance. This webinar will examine these special rules to simplify the TBI coding process.

At the conclusion of this webinar, participants will be able to:

  • Discuss definitions, medical terms and basic brain anatomy specific to TBI
  • Articulate the importance of correct documentation for TBI and correct ICD-9-CM coding and compliance
  • Analyze initial and subsequent TBI encounter documentation and validate and/or identify appropriate ICD-9-CM codes

Amy Waller, CPC, CPMA, CPCO
American Health Information Management Association approved ICD-10-CM/PCS Trainer/Ambassador
Senior ICD-10 Trainer
Team: Dynamics Research Corporation/Standard Technology, INC.
Arlington, Va./Bethesda, Md.

Sherray L. Holland, PA-C
TBI Clinical Educator, Education Division
Contract support to DVBIC
Silver Spring, Md.

Continuing Education
Continuing education credit is available from Duke Medicine. You must register on or before Aug. 14, 2014, at 3 p.m. (EDT) to qualify for the receipt of continuing education credit.

To qualify for receipt of continuing education credit for applicable webinars, eligible participants must create a profile in the Duke Medicine Learning Management System and register for the event on, or before, the event registration deadline. Complete responses to all pre-registration questions are required to be eligible to receive credit for attending this event. For guidance on creating a user account and event registration in the Duke Medicine Learning Management System site, please visit

The awarding of continuing education credit is limited in scope to health care providers who actively provide psychological health and traumatic brain injury care to U.S. active-duty service members, reservists, National Guardsmen, military veterans and/or their families.

For additional details, please visit

Sign up for the webinar at