Measure #2: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years

Transcription

1 ACEP DRAFT Quality Measures for Public Comment Obsolete After: October 17, 2014 Page 10 of 23 Measure #2: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years For this measure lower score indicates higher quality Measure Description Percentage of emergency department visits for patients aged 2 through 17 years presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider and are classified as low risk according to the PECARN prediction rules for traumatic brain injury Measure Components Numerator Statement Denominator emergency department visits for patients classified as low risk according to the PECARN prediction rules for traumatic brain injury Definition: Low Risk for Traumatic Brain Injury according to PECARN prediction rules Patients can be classified as low risk if all of the following are met: No signs of altered mental status (eg, agitation, somnolence, repetitive questioning, slow response to verbal communication) No signs of basilar skull fracture (signs include haemotympanum, panda eyes, cerebrospinal fluid leakage from the ear or nose, Battle s sign) No loss of consciousness No vomiting No severe mechanism of injury (ie, motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 3 feet; or head struck by a highimpact object) No severe headache Denominator Statement All emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider Definition: Presented within 24 hours - The 24 hour timeframe is based on the time of injury reported by the patient or guardian. Denominator Exclusions Denominator note: Minor blunt head trauma includes only non-penetrating injuries. Patients with any of the following: Ventricular shunt Brain tumor Coagulopathy Thrombocytopenia American College of Emergency Physicians. All Rights Reserved. CPT Copyright American Medical Association. Submit Comments at

2 ACEP DRAFT Quality Measures for Public Comment Obsolete After: October 17, 2014 Page 11 of 23 Denominator Exceptions Rationale for the Measure None This measure is needed to close the gap in provider performance as patients with mild closed head injuries without guideline indications for CT or MRI imaging are receiving such studies. The results of this are increased healthcare expenditures, unnecessary patient radiation exposure, and possibly prolonged evaluation times.. This measure is an overuse measure its intention is to capture those instances in which a pediatric patient is characterized as low risk yet still receives a CT. As such, the measure is scored such that a lower score indicates higher quality. The measure is constructed in this manner due to the available evidence; the PECARN clinical policy defines the low-risk population, but though medium and high risk populations are less well-defined. The measure then uses the definable population as its numerator, necessitating an overuse construction. Supporting Guideline & Other Evidence The following evidence statements are quoted verbatim from the referenced clinical guidelines and other references: Pediatric Emergency Care Applied Research Network (PECARN): Suggested CT algorithm for children younger than 2 years (A) and for those aged 2 years and older (B) with GCS scores of after head trauma: American College of Emergency Physicians. All Rights Reserved. CPT Copyright American Medical Association. Submit Comments at

3 ACEP DRAFT Quality Measures for Public Comment Obsolete After: October 17, 2014 Page 12 of 23 NICE: Head Injury Triage, assessment, investigation and early management of head injury in children and adultsxii For children who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified: Suspicion of non-accidental injury Post-traumatic seizure but no history of epilepsy. On initial emergency department assessment, GCS less than 14. At 2 hours after the injury, GCS less than 15. Suspected open or depressed skull fracture or tense fontanelle. Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). Focal neurological deficit For children who have sustained a head injury and have more than 1 of the following risk factors (and none of those in recommendation 1.4.9), perform a CT head scan within 1 hour of the risk factors being identified: American College of Emergency Physicians. All Rights Reserved. CPT Copyright American Medical Association. Submit Comments at

4 ACEP DRAFT Quality Measures for Public Comment Obsolete After: October 17, 2014 Page 13 of 23 Measure Importance Loss of consciousness lasting more than 5 minutes (witnessed). Abnormal drowsiness. Three or more discrete episodes of vomiting. Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object). Amnesia (antegrade or retrograde) lasting more than 5 minutes4. A provisional written radiology report should be made available within 1 hour of the scan being performed. [new 2014] Relationship to Desired Outcome Opportunity for Improvement Exception Justification Though it is difficult to directly attribute the effects of smaller dosages of radiation, such as that received through computed tomography (CT), there is evidence to suggest that the low dose radiation emitted through the use of some CT scans is associated with a significant risk of cancer, particularly in children. xiii As over 1.3 million individuals are treated and released from the ED for mild traumatic brain injury annually xiv, it is critical that CT scans only be utilized when clinically appropriate. Through measurement of the share of CT scans that are performed inappropriately, a focus can be brought to quality improvement and increased application of clinical decision tools around this topic. About 2.5 million traumatic brain injuries occur each year, where 75% of these are considered mild. xv There is data to suggest that 70% of head injury patients receive a head CT xvi, and it is estimated that 10-35% of head CTs obtained in head injury patients do not follow recognized guidelines. xvii Some estimate that as many as 55, ,000 CT scans are possibly avoidable annually. xviii The ACEP Measure Work Group agreed to include appropriate medical reasons as an exception so that clinicians can exclude patients for whom CT imaging may be justified. Harmonization with Existing Measures Measure Designation Measure purpose Type of measure National Quality Strategy Priority-CMS Measure Domain (check all that apply) Staff have considered harmonization with NQF 0668 Appropriate Head CT Imaging in Adults with Mild Traumatic Brain Injury. This measure will update NQF #0668 for implementation. Quality improvement Accountability MOC Process Outcome Structure Clinical Process-Effectiveness Patient Safety Patient Experience Care Coordination Efficiency: Overuse American College of Emergency Physicians. All Rights Reserved. CPT Copyright American Medical Association. Submit Comments at

5 ACEP DRAFT Quality Measures for Public Comment Obsolete After: October 17, 2014 Page 14 of 23 Level of Measurement (check all that apply) Care setting (check all that apply) Data source (check all that apply) Efficiency: Cost Population & Community Health Individual clinicians Clinician groups Hospital Outpatient/ED Emergency Departments Urgent Care Harmonize with other care settings o Physician Office Based Measures o Hospital Level Measure Electronic health record (EHR) data Administrative Data/Claims (inpatient, outpatient or multiple-source claims) Paper medical record/chart abstracted Registry American College of Emergency Physicians. All Rights Reserved. CPT Copyright American Medical Association. Submit Comments at

6 American College of Emergency Physicians (ACEP) Data Requirements Table Measure Component Supplemental Data Elements Initial Population Measure #2: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years QDM* Standard Category QDM* Data Type Value Set Name Standard Terminology OID Constraints Comments/Rationale Individual Characteristic Patient Characteristic ONC Administrative Sex Administrative Sex (HL7 v2.5) during measurement period Individual Characteristic Patient Characteristic Race CDC during measurement period Individual Characteristic Patient Characteristic Ethnicity CDC during measurement period Individual Characteristic Patient Characteristic Payer Source of Payment Typology during measurement period Measure Timing n/a Measurement Period n/a n/a by Measure Implementer Individual Characteristic Patient Characteristic age Calculation n/a Encounter Condition / Diagnosis / Problem Encounter, Performed Diagnosis, Active Emergency Department Visit, Occurrence A Non-Penetrating Head Trauma, Occurrence A CPT ICD-9-CM ICD-10-CM >= 2 years AT Measurement Period AND < 18 years AT Measurement Period during Measurement Period <= 24 hours starts before start of [Occurrence A of Encounter, Performed: Emergency Department Visit] This data element is collected for the purpose of stratifying results in an effort to highlight disparities. This data element is collected for the purpose of stratifying results in an effort to highlight disparities. This data element is collected for the purpose of stratifying results in an effort to highlight disparities. This data element is collected for the purpose of stratifying results in an effort to highlight disparities. Measurement Period start date minus Birth Date must be greater than or equal to 2 years and less than 18 years. The timing of this data element is reported by the patient or the patient's caregiver or guardian. Equals Initial Population Denominator Risk Category during [Occurrence A of Encounter, Risk Category Assessment Glasgow Coma Scale Assessment LOINC Attribute Attribute: Result = 15 n/a n/a n/a This attribute is applied to the value set titled 'Glasgow Coma Scale'. Diagnostic Study Diagnostic Study, Order Head CT CPT during [Occurrence A of Encounter, To meet this data element, an emergency care provider must have ordered the Head CT for trauma. Denominator Exclusions Condition / Diagnosis / Problem Condition / Diagnosis / Problem Diagnosis, Active Diagnosis, Active Ventricular Shunt Brain Tumor ICD-9-CM ICD-10-CM ICD-9-CM Condition / Diagnosis / Problem Diagnosis, Active Coagulopathies ICD-10-CM ICD-9-CM Condition / Diagnosis / Problem Diagnosis, Active Thrombocytopenia ICD-10-CM ICD-9-CM ICD-10-CM overlaps [Occurrence A of Encounter, overlaps [Occurrence A of Encounter, overlaps [Occurrence A of Encounter, overlaps [Occurrence A of Encounter, Symptom Symptom, Active Signs of Altered Mental Status starts during [Occurrence A of Encounter, Numerator Symptom Symptom Symptom, Active Symptom, Active Loss of Consciousness Physical Signs of Basilar Skull Fracture Symptom Symptom, Active Vomiting starts during [Occurrence A of Encounter, starts during [Occurrence A of Encounter, starts during [Occurrence A of Encounter, This data element is meant to capture patient symptoms that present after the 'Non-Penetrating Head Trauma'. However, the timestamp that would be logged within the EHR would likely be during the emergency department visit, even though the symptom actually became active prior to admission to the emergency department. Symptom Symptom, Active Severe Headache starts during [Occurrence A of Encounter, Attribute Attribute: Reason Dangerous Mechanism of Injury n/a This attribute is applied to the data element 'Non-Penetrating Head Trauma'. Denominator Exceptions There are no valid denominator exceptions. Quality Data Model (QDM), Version 4.1.

7 American College of Emergency Physicians Measure #2: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years Denominator (Eligible Population) All emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider Definition: Presented within 24 hours - The 24 hour timeframe is based on the time of injury reported by the patient or guardian. Denominator note: Minor blunt head trauma includes only non-penetrating injuries. Age 2-17 years AND CPT Code for Encounter: 99281, 99282, 99283, 99284, AND ICD-9-CM Diagnosis Code for non-penetrating head injury (reportable through 9/30/2015): Code Descriptor Closed fracture of vault of skull without mention of intracranial injury, unspecified state of consciousness Closed fracture of vault of skull without mention of intracranial injury, with no loss of consciousness Closed fracture of vault of skull without mention of intracranial injury, with brief [less than one hour] loss of consciousness Closed fracture of vault of skull without mention of intracranial injury, with moderate [1-24 hours] loss of consciousness Closed fracture of vault of skull without mention of intracranial injury, with loss of consciousness of unspecified duration Closed fracture of vault of skull without mention of intracranial injury, with concussion, unspecified Closed fracture of vault of skull with cerebral laceration and contusion, unspecified state of consciousness Closed fracture of vault of skull with cerebral laceration and contusion, with no loss of consciousness Closed fracture of vault of skull with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness Closed fracture of vault of skull with cerebral laceration and contusion, with moderate [1-24 hours] loss of consciousness Closed fracture of vault of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration Closed fracture of vault of skull with cerebral laceration and contusion, with concussion, unspecified Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with moderate [1-24 hours] loss of consciousness Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified Closed fracture of vault of skull with other and unspecified intracranial hemorrhage,

8 American College of Emergency Physicians unspecified state of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with brief [less than one hour] loss of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with moderate [1-24 hours] loss of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with concussion, unspecified Closed fracture of vault of skull with intracranial injury of other and unspecified nature, unspecified state of consciousness Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with no loss of consciousness Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with brief [less than one hour] loss of consciousness Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with moderate [1-24 hours] loss of consciousness Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with concussion, unspecified Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness Closed fracture of base of skull without mention of intra cranial injury, with brief [less than one hour] loss of consciousness Closed fracture of base of skull without mention of intra cranial injury, with moderate [1-24 hours] loss of consciousness Closed fracture of base of skull without mention of intra cranial injury, with loss of consciousness of unspecified duration Closed fracture of base of skull without mention of intra cranial injury, with concussion, unspecified Closed fracture of base of skull with cerebral laceration and contusion, unspecified state of consciousness Closed fracture of base of skull with cerebral laceration and contusion, with no loss of consciousness Closed fracture of base of skull with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness Closed fracture of base of skull with cerebral laceration and contusion, with moderate [1-24 hours] loss of consciousness Closed fracture of base of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration Closed fracture of base of skull with cerebral laceration and contusion, with concussion, unspecified Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with moderate [1-24 hours] loss of consciousness Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified Closed fracture of base of skull with other and unspecified intracranial hemorrhage, unspecified state of consciousness

9 American College of Emergency Physicians Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with no loss of consciousness Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with brief [less than one hour] loss of consciousness Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with moderate [1-24 hours] loss of consciousness Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with concussion, unspecified Closed fracture of base of skull with intracranial injury of other and unspecified nature, unspecified state of consciousness Closed fracture of base of skull with intracranial injury of other and unspecified nature, with no loss of consciousness Closed fracture of base of skull with intracranial injury of other and unspecified nature, with brief [less than one hour] loss of consciousness Closed fracture of base of skull with intracranial injury of other and unspecified nature, with moderate [1-24 hours] loss of consciousness Closed fracture of base of skull with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration Closed fracture of base of skull with intracranial injury of other and unspecified nature, with concussion, unspecified Closed fracture of nasal bones Closed fracture of mandible, unspecified site Closed fracture of mandible, condylar process Closed fracture of mandible, subcondylar Closed fracture of mandible, coronoid process Closed fracture of mandible, ramus, unspecified Closed fracture of mandible, angle of jaw Closed fracture of mandible, symphysis of body Closed fracture of mandible, alveolar border of body Closed fracture of mandible, body, other and unspecified Closed fracture of mandible, multiple sites Closed fracture of malar and maxillary bones Closed fracture of orbital floor (blow-out) Closed fracture of other facial bones Other closed skull fracture without mention of intracranial injury, unspecified state of consciousness Other closed skull fracture without mention of intracranial injury, with no loss of consciousness Other closed skull fracture without mention of intracranial injury, with brief [less than one hour] loss of consciousness Other closed skull fracture without mention of intracranial injury, with moderate [1-24 hours] loss of consciousness Other closed skull fracture without mention of intracranial injury, with loss of consciousness of unspecified duration Other closed skull fracture without mention of intracranial injury, with concussion, unspecified Other closed skull fracture with cerebral laceration and contusion, unspecified state of consciousness Other closed skull fracture with cerebral laceration and contusion, with no loss of consciousness Other closed skull fracture with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness Other closed skull fracture with cerebral laceration and contusion, with moderate [1-24 hours] loss of consciousness Other closed skull fracture with cerebral laceration and contusion, with loss of consciousness of unspecified duration

10 American College of Emergency Physicians Other closed skull fracture with cerebral laceration and contusion, with concussion, unspecified Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with moderate [1-24 hours] loss of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified Other closed skull fracture with other and unspecified intracranial hemorrhage, unspecified state of unconsciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, with no loss of consciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, with brief [less than one hour] loss of consciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, with moderate [1-24 hours] loss of consciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration Other closed skull fracture with other and unspecified intracranial hemorrhage, with concussion, unspecified Other closed skull fracture with intracranial injury of other and unspecified nature, unspecified state of consciousness Other closed skull fracture with intracranial injury of other and unspecified nature, with no loss of consciousness Other closed skull fracture with intracranial injury of other and unspecified nature, with brief [less than one hour] loss of consciousness Other closed skull fracture with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration Other closed skull fracture with intracranial injury of other and unspecified nature, with concussion, unspecified Closed fractures involving skull or face with other bones, without mention of intracranial injury, unspecified state of consciousness Closed fractures involving skull or face with other bones, without mention of intracranial injury, with no loss of consciousness Closed fractures involving skull or face with other bones, without mention of intracranial injury, with brief [less than one hour] loss of consciousness Closed fractures involving skull or face with other bones, without mention of intracranial injury, with moderate [1-24 hours] loss of consciousness Closed fractures involving skull of face with other bones, without mention of intracranial injury, with loss of consciousness of unspecified duration Closed fractures involving skull of face with other bones, without mention of intracranial injury, with concussion, unspecified Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, unspecified state of consciousness Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with no loss of consciousness Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with brief [less than one hour] loss of consciousness Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with moderate [1-24 hours] loss of consciousness Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with loss of consciousness of unspecified duration Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, with concussion, unspecified Closed fractures involving skull or face with other bones with subarachnoid,

11 American College of Emergency Physicians subdural, and extradural hemorrhage, unspecified state of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with moderate [1-24 hours] loss of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with concussion, unspecified Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, unspecified state of consciousness Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with no loss of consciousness Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with brief [less than one hour] loss of consciousness Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with moderate [1-24 hours] loss of consciousness Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration Closed fractures involving skull or face with other bones, with other and unspecified intracranial hemorrhage, with concussion, unspecified Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, unspecified state of consciousness Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with no loss of consciousness Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with brief [less than one hour] loss of consciousness Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with moderate [1-24 hours] loss of consciousness Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with loss of consciousness of unspecified duration Closed fractures involving skull or face with other bones, with intracranial injury of other and unspecified nature, with concussion, unspecified Concussion with no loss of consciousness Concussion, with loss of consciousness of 30 minutes or less Concussion, with loss of consciousness from 31 to 59 minutes Concussion with moderate loss of consciousness Concussion with loss of consciousness of unspecified duration Concussion, unspecified Cortex (cerebral) contusion without mention of open intracranial wound, unspecified state of consciousness Cortex (cerebral) contusion without mention of open intracranial wound, with no loss of consciousness Cortex (cerebral) contusion without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Cortex (cerebral) contusion without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Cortex (cerebral) contusion without mention of open intracranial wound, with loss of consciousness of unspecified duration Cortex (cerebral) contusion without mention of open intracranial wound, with concussion, unspecified Cortex (cerebral) laceration without mention of open intracranial wound, unspecified state of consciousness Cortex (cerebral) laceration without mention of open intracranial wound, with no loss

12 American College of Emergency Physicians of consciousness Cortex (cerebral) laceration without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Cortex (cerebral) laceration without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Cortex (cerebral) laceration without mention of open intracranial wound, with loss of consciousness of unspecified duration Cortex (cerebral) laceration without mention of open intracranial wound, with concussion, unspecified Cerebellar or brain stem contusion without mention of open intracranial wound, unspecified state of consciousness Cerebellar or brain stem contusion without mention of open intracranial wound, with no loss of consciousness Cerebellar or brain stem contusion without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Cerebellar or brain stem contusion without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Cerebellar or brain stem contusion without mention of open intracranial wound, with loss of consciousness of unspecified duration Cerebellar or brain stem contusion without mention of open intracranial wound, with concussion, unspecified Cerebellar or brain stem laceration without mention of open intracranial wound, unspecified state of consciousness Cerebellar or brain stem laceration without mention of open intracranial wound, with no loss of consciousness Cerebellar or brain stem laceration without mention of open intracranial wound, with brief [less than 1 hour] loss of consciousness Cerebellar or brain stem laceration without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Cerebellar or brain stem laceration without mention of open intracranial wound, with loss of consciousness of unspecified duration Cerebellar or brain stem laceration without mention of open intracranial wound, with concussion, unspecified Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, unspecified state of consciousness Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with concussion, unspecified Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Subarachnoid hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Subarachnoid hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Subarachnoid hemorrhage following injury without mention of open intracranial wound, with concussion, unspecified Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness

13 American College of Emergency Physicians Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Subdural hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Subdural hemorrhage following injury without mention of open intracranial wound, with concussion, unspecified Extradural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Extradural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Extradural hemorrhage following injury without mention of open intracranial wound, with brief [less than 1 hour] loss of consciousness Extradural hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Extradural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Extradural hemorrhage following injury without mention of open intracranial wound, with concussion, unspecified Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with concussion, unspecified Intracranial injury of other and unspecified nature without mention of open intracranial wound, unspecified state of consciousness Intracranial injury of other and unspecified nature without mention of open intracranial wound, with no loss of consciousness Intracranial injury of other and unspecified nature without mention of open intracranial wound, with brief [less than one hour] loss of consciousness Intracranial injury of other and unspecified nature without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness Intracranial injury of other and unspecified nature without mention of open intracranial wound, with loss of consciousness of unspecified duration Intracranial injury of other and unspecified nature without mention of open intracranial wound, with concussion, unspecified 920 Contusion of face, scalp, and neck except eye(s) Head injury, unspecified ICD-10-CM Diagnosis Code for non-penetrating head injury (reportable beginning 10/1/2015): Code Descriptor S00.03XA Contusion of scalp, S00.33XA Contusion of nose, S00.431A Contusion of right ear, S00.432A Contusion of left ear, S00.439A Contusion of unspecified ear, S00.531A Contusion of lip, S00.532A Contusion of oral cavity, S00.83XA Contusion of other part of head,

14 American College of Emergency Physicians S00.93XA S02.0XXA S02.10XA S02.110A S02.111A S02.112A S02.113A S02.118A S02.119A S02.19XA S02.2XXA S02.3XXA S02.400A S02.401A S02.402A S02.411A S02.412A S02.413A S02.42XA S02.600A S02.609A S02.61XA S02.62XA S02.63XA S02.64XA S02.65XA S02.66XA S02.67XA S02.69XA S02.8XXA S02.91XA S02.92XA S06.0X0A S06.0X1A S06.0X2A S06.0X3A S06.0X4A S06.0X9A S06.1X0A S06.1X1A S06.1X2A S06.1X3A S06.1X4A S06.1X9A Contusion of unspecified part of head, Fracture of vault of skull, for closed fracture Unspecified fracture of base of skull, for closed fracture Type I occipital condyle fracture, for closed fracture Type II occipital condyle fracture, for closed fracture Type III occipital condyle fracture, for closed fracture Unspecified occipital condyle fracture, for closed fracture Other fracture of occiput, for closed fracture Unspecified fracture of occiput, for closed fracture Other fracture of base of skull, for closed fracture Fracture of nasal bones, for closed fracture Fracture of orbital floor, for closed fracture Malar fracture unspecified, for closed fracture Maxillary fracture, unspecified, for closed fracture Zygomatic fracture, unspecified, for closed fracture LeFort I fracture, for closed fracture LeFort II fracture, for closed fracture LeFort III fracture, for closed fracture Fracture of alveolus of maxilla, for closed fracture Fracture of unspecified part of body of mandible, for closed fracture Fracture of mandible, unspecified, for closed fracture Fracture of condylar process of mandible, for closed fracture Fracture of subcondylar process of mandible, for closed fracture Fracture of coronoid process of mandible, for closed fracture Fracture of ramus of mandible, for closed fracture Fracture of angle of mandible, for closed fracture Fracture of symphysis of mandible, for closed fracture Fracture of alveolus of mandible, for closed fracture Fracture of mandible of other specified site, for closed fracture Fractures of other specified skull and facial bones, for closed fracture Unspecified fracture of skull, for closed fracture Unspecified fracture of facial bones, for closed fracture Concussion without loss of consciousness, Concussion with loss of consciousness of 30 minutes or less, Concussion with loss of consciousness of 31 minutes to 59 minutes, initial Concussion with loss of consciousness of 1 hour to 5 hours 59 minutes, initial Concussion with loss of consciousness of 6 hours to 24 hours, Concussion with loss of consciousness of unspecified duration, Traumatic cerebral edema without loss of consciousness, Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, Traumatic cerebral edema with loss of consciousness of unspecified duration,

15 American College of Emergency Physicians S06.2X0A S06.2X1A S06.2X2A S06.2X3A S06.2X4A S06.2X9A S06.300A S06.301A S06.302A S06.303A S06.304A S06.309A S06.310A S06.311A S06.312A S06.313A S06.314A S06.319A S06.320A S06.321A S06.322A S06.323A S06.324A S06.329A S06.330A S06.331A S06.332A S06.333A S06.334A S06.339A S06.340A Diffuse traumatic brain injury without loss of consciousness, Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours, Diffuse traumatic brain injury with loss of consciousness of unspecified duration, Unspecified focal traumatic brain injury without loss of consciousness, initial Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, Contusion and laceration of right cerebrum without loss of consciousness, initial Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less, Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24 hours, Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, Contusion and laceration of left cerebrum without loss of consciousness, initial Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less, Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours, Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, Contusion and laceration of cerebrum, unspecified, without loss of consciousness, Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, Traumatic hemorrhage of right cerebrum without loss of consciousness, initial

16 S06.341A S06.342A S06.343A S06.344A S06.349A S06.350A S06.351A S06.352A S06.353A S06.354A S06.359A S06.360A S06.361A S06.362A S06.363A S06.364A S06.369A S06.370A S06.371A S06.372A S06.373A S06.374A S06.379A S06.380A S06.381A S06.382A S06.383A S06.384A S06.389A S06.4X0A S06.4X1A American College of Emergency Physicians Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less, Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours, Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration, Traumatic hemorrhage of left cerebrum without loss of consciousness, initial Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59 minutes, Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59 minutes, Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours, Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration, Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30 minutes or less, Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31 minutes to 59 minutes, Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to 5 hours 59 minutes, Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours to 24 hours, Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of unspecified duration, Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30 minutes or less, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31 minutes to 59 minutes, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to 5 hours 59 minutes, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to 24 hours, Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, Epidural hemorrhage without loss of consciousness, Epidural hemorrhage with loss of consciousness of 30 minutes or less, initial

17 S06.4X2A S06.4X3A S06.4X4A S06.4X9A S06.5X0A S06.5X1A S06.5X2A S06.5X3A S06.5X4A S06.5X9A S06.6X0A S06.6X1A S06.6X2A S06.6X3A S06.6X4A S06.6X9A S06.810A S06.811A S06.812A S06.813A S06.814A S06.819A S06.820A S06.821A S06.822A S06.823A S06.824A S06.829A S06.890A S06.891A S06.892A American College of Emergency Physicians Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial Epidural hemorrhage with loss of consciousness of unspecified duration, initial Traumatic subdural hemorrhage without loss of consciousness, Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, Traumatic subarachnoid hemorrhage without loss of consciousness, initial Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, Injury of right internal carotid artery, intracranial portion, not elsewhere classified without loss of consciousness, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 30 minutes or less, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 31 minutes to 59 minutes, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 1 hour to 5 hours 59 minutes, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 6 hours to 24 hours, Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of unspecified duration, Injury of left internal carotid artery, intracranial portion, not elsewhere classified without loss of consciousness, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 30 minutes or less, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 31 minutes to 59 minutes, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 1 hour to 5 hours 59 minutes, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of 6 hours to 24 hours, Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of consciousness of unspecified duration, Other specified intracranial injury without loss of consciousness, Other specified intracranial injury with loss of consciousness of 30 minutes or less, Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes,