Live Syllabus

DEFINITION:

Code the living status of the person with brain injury. If patient has died, code the cause of death.

Instructions for coding ICD-9-CM primary and secondary causes of death are in 16a.Guidelines coding cause of death in Appendix C. Instructions for coding the E-code cause of death are in 24b.Guidelines for Coding Cause of Injury and Etiology of Injury (E-codes) in Appendix K.

CODE:

Code the two boxes for the ICD-9-CM codes and the box for the External Cause of Injury Codes (E-codes) as follows.

ICD-9-CM code boxes:
For a list of ICD-9 codes, refer to an ICD-9 code manual at your facility.

777.77 Person expired but cause of death unknown
888.88 Not Applicable--person alive, or no other internal cause of death indicated, or death due to external causes
999.99 Unknown if person expired

E-code box:
For an abbreviated list of E-codes, see: 24a.ICD-9-CM E-code categories in Appendix K. A complete list of E-codes is available at E-Code list-complete.

*77777 Person expired but cause of death unknown
*88888 Not Applicable--person alive or death not due to external causes
*99999 Unknown if person expired

NOTE:

If autopsy was performed obtain report, document cause(s) of death by use of ICD-9-CM diagnosis codes or E-code if applicable. Record date of death in Variable 201.

If patient expired, complete only variables 20Aa through 201 then stop.

The look-up boxes on the database screen provide the E-Codes and their definitions. When taking E-Codes from the Medical Record, they should be checked to ensure that they reflect the best / most current information available about the cause of the injury. Data collectors may submit E-Codes that differ from those recorded in the Medical Record in cases where they feel the Medical Record E-Codes may not reflect the best / most current information available. There should be clear documentation on the data collection form when an E-Code entered into the database does not reflect the E-Code recorded in the Medical Record. In unusual cases where no E-Code relative to the injury that resulted in traumatic brain injury is recorded in the Medical Record, the data collector should use best judgement and the consultation of other personnel, as necessary, to determine the appropriate E-Code from the TBIMS database list.