MEDICAL POLICY POLICY TITLE POLICY NUMBER NEUROPSYCHOLOGICAL TESTING (FOR MEDICAL PURPOSES) MP-4.027

Transcription

1 Original Issue Date (Created): July 1, 2005 Most Recent Review Date (Revised): November 26, 2013 Effective Date: February 1, 2014 I. POLICY Neuropsychological testing may be considered medically necessary for the following (but not limited to) conditions: Cerebrovascular disease (e.g., CVA, TIA, stroke); Delirium or other confusion states; Dementia (e.g., Alzheimer s disease); Hydrocephalus; Intracranial neoplasm; Movement disorders (e.g., Parkinson s disease); Multiple sclerosis; Seizure disorders, including epilepsy; Traumatic brain injury; or Depression or other mental health diagnoses, including chemical dependency, presenting primarily with neurological symptoms or a medical condition. The initial test and repeat testing may be covered when needed to assess or determine a treatment change, when there is a reasonable suspicion of a new problem or when needed to reconfirm a diagnosis (e.g., following deterioration or change of the patient s condition) and the results of testing are expected to impact the patient s management or outcome. Periodic testing of stable patients would be considered not medically necessary. NPT is not covered when done for the following: Educational purposes; Mental health diagnoses, including substance abuse (may warrant individual consideration). Page 1

2 Occupational exposure to toxic substances (may be covered through worker s compensation channels); Patients with stable conditions; or Screening purposes; Brief isolated screening measures (e.g., Folstein Mini Mental Status Exam) should not be classified or reimbursed as NPT, as they are typically part of a more general clinical examination. Neuropsychological assessments that can be obtained through the clinical evaluation alone (e.g., response to medication) would not necessarily require psychological testing. Also excluded from coverage are self-administered tests or self-scored inventories such as the Holmes and Rahe Social Readjustment Rating Scale, the Minnesota Multiphasic Personality Inventory, or the Hamilton Depression Rating Scale. Likewise, projective techniques such as the Rorschach or Thematic Apperception Test are not covered. II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] Capital Cares 4 Kids [N] PPO [N] HMO [N] SeniorBlue HMO [N] SeniorBlue PPO [N] Indemnity [N] SpecialCare [N] POS [N] FEP PPO III. DESCRIPTION/BACKGROUND Neuropsychological testing (NPT) is used as an aid in the evaluation and management of neuropsychological abnormalities. NPT is intended to facilitate the evaluation and characterization of the neurocognitive effects of medical disorders that directly or indirectly affect the brain. NPT differs from psychological testing in that NPT consists of a battery of individually administered tests that comprehensively sample ability domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensory-motor functions, constructional praxis, etc.). These procedures are objective and quantitative in nature and require the patient to directly demonstrate his/her level of competence in a particular cognitive domain. Examples Page 2

3 include the Halstead-Reitan Neuropsychological Battery, the Luria-Nebraska Neuropsychological Battery, and the Wechsler Adult Intelligence Scale-Revised. IV. DEFINITIONS N/A V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. Clin Neuropsychol Mar;21(2): [Website]: Accessed September 16, Malik A, McDonald D. Neuropsychological Evaluation. Last updated April 2, emedicine [Website]: Accessed September 16, Nokleby, K, Boland, E, Bergersen, H, Schanke, AK, Farner, L, Wagle, J, and Wyller, TB. Screening for cognitive deficits after stroke: a comparison of three screening tools. Clin Rehabil. 2008;22(12): Pokryszko-Dragan, A, Zagrajek, M, Slotwinski, K, et al. Neuropsychological testing and event-related potentials in the assessment of cognitive performance in the patients with multiple sclerosis-a pilot study. Clin Neurol Neurosurg Page 3

4 Randolph, C, Hilsabeck, R, Kato, A, et al. Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines. Liver Int Sartori E,Edan G. Assessment of cognitive dysfunction in multiple sclerosis. J Neurol Sci. 2006;245(1-2): Shadlen MF, Larson E. Evaluation of cognitive impairment and dementia. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated August 30, [Website]: Accessed September 16, VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved Unspecified juvenile neurosyphilis Syphilitic parkinsonism Malignant neoplasm of cerebrum, except lobes and ventricles Malignant neoplasm of frontal lobe Malignant neoplasm temporal lobe Malignant neoplasm of parietal lobe Malignant neoplasm of occipital lobe Malignant neoplasm of ventricles Malignant neoplasm of cerebellum Malignant neoplasm of brain stem Page 4

5 191.9 Malignant neoplasm of brain, unspecified site Malignant neoplasm of cranial nerves Malignant neoplasm of cerebral meninges Secondary malignant neoplasm of brain and spinal cord Neoplasm of uncertain behavior of brain and spinal cord Neoplasm of uncertain nature of brain Senile dementia, uncomplicated Senile dementia with delirium Other specified senile psychotic conditions Unspecified senile psychotic condition Presenile dementia, uncomplicated Presenile dementia with delirium Presenile dementia with delusional features Presenile dementia with depressive features Senile dementia with delusional features Senile dementia with depressive features Senile dementia with delirium Vascular dementia, uncomplicated Vascular dementia, with delirium Vascular dementia, with delusions Vascular dementia, with depressed mood Alcohol-induced persisting amnestic disorder Alcohol-induced psychotic disorder with delusions Alcohol withdrawal Unspecified alcohol-induced mental disorders Page 5

6 292.0 Drug withdrawal Drug-induced psychotic disorder with delusions Drug-induced persisting dementia Drug-induced persisting amnestic disorder Drug-induced mood disorder Other specified drug-induced mental disorder Unspecified drug-induced mental disorder Delirium due to conditions classified elsewhere Subacute delirium Psychotic disorder with delusions in conditions classified elsewhere Psychotic disorder with hallucinations in conditions classified elsewhere Mood disorder in conditions classified elsewhere Anxiety disorder in conditions classified elsewhere Other transient mental disorders due to conditions classified elsewhere Unspecified transient mental disorder in conditions classified elsewhere Amnestic disorder in conditions classified elsewhere Dementia in conditions classified elsewhere Other persistent mental disorders due to conditions classified elsewhere Dementia in conditions classified elsewhere without behavioral disturbance Dementia in conditions classified elsewhere with behavioral disturbance Dementia, unspecified, without behavioral disturbance Other persistent mental disorders due to conditions classified elsewhere Unspecified persistent mental disorders due to conditions classified elsewhere Disorganized schizophrenia, unspecified condition Catatonic schizophrenia, unspecified condition Page 6

7 Paranoid schizophrenia, unspecified condition Schizophreniform disorder, unspecified Schizophrenic disorders, residual type, in remission Schizoaffective disorder, unspecified Unspecified schizophrenia, unspecified condition Bipolar i disorder, single manic episode, unspecified Manic disorder, recurrent episode, unspecified Major depressive disorder, single episode, unspecified Major depressive disorder, recurrent episode, unspecified Bipolar i disorder, most recent episode (or current) manic, unspecified Bipolar i disorder, most recent episode (or current) mixed, unspecified Bipolar i disorder, most recent episode (or current) unspecified Bipolar disorder, unspecified Atypical manic disorder Atypical depressive disorder Other and unspecified bipolar disorders Unspecified episodic mood disorder Delusional disorder Shared psychotic disorder Other and unspecified reactive psychosis Unspecified psychosis Autistic disorder, current or active state Childhood disintegrative disorder, current or active state Other specified pervasive developmental disorders, current or active state Panic disorder without agoraphobia Page 7

8 Generalized anxiety disorder Conversion disorder Other and unspecified factitious illness Agoraphobia with panic disorder Other isolated or specific phobias Obsessive-compulsive disorders Dysthymic disorder Depersonalization disorder Hypochondriasis Undifferentiated somatoform disorder Psychosexual dysfunction, unspecified Psychosexual dysfunction with other specified psychosexual dysfunctions Other and unspecified alcohol dependence, unspecified drunkenness Opioid type dependence, unspecified abuse Nondependent cannabis abuse, unspecified Anorexia nervosa Tic disorder, unspecified Stereotypic movement disorder Persistent disorder of initiating or maintaining sleep Persistent disorder of initiating or maintaining wakefulness Sleep arousal disorder Eating disorder, unspecified Other disorder of eating Psychogenic pain, site unspecified Other pain disorder related to psychological factors Page 8

9 308.3 Other acute reactions to stress Adjustment disorder with depressed mood Prolonged depressive reaction as adjustment reaction Separation anxiety disorder Specific academic or work inhibition as adjustment reaction Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder with disturbance of conduct Adjustment disorder with mixed disburbance of emotions and conduct Posttraumatic stress disorder Personality change due to conditions classified elsewhere 311. Depressive disorder, not elsewhere classified Conduct disorder, childhood onset type Conduct disorder, adolescent onset type Other specified disturbance of conduct, not elsewhere classified Selective mutism Oppositional defiant disorder Identity disorder of childhood or adolescence Attention deficit disorder of childhood without mention of hyperactivity Attention deficit disorder of childhood with hyperactivity Hyperkinesis of childhood with developmental delay Hyperkinetic conduct disorder of childhood Other specified manifestations of hyperkinetic syndrome of childhood Unspecified hyperkinetic syndrome of childhood Developmental reading disorder, unspecified Page 9

10 Other specific developmental reading disorder Mathematics disorder Other specific developmental learning difficulties Expressive language disorder Mixed receptive-expressive language disorder Other developmental speech or language disorder Developmental coordination disorder Mixed development disorder Other specified delay in development Unspecified delay in development 317. Mild mental retardation Moderate mental retardation Severe mental retardation Alzheimer's disease Communicating hydrocephalus Obstructive hydrocephalus Idiopathic normal pressure hydrocephalus [INPH] Cerebral degeneration in diseases classified elsewhere Other frontotemporal dementia Paralysis agitans Unspecified extrapyramidal disease and abnormal movement disorder Neuroleptic malignant syndrome Other extrapyramidal disease and abnormal movement disorder 340 Multiple sclerosis Generalized nonconvulsive epilepsy without mention of intractable epilepsy Page 10

11 Generalized nonconvulsive epilepsy with intractable epilepsy Generalized convulsive epilepsy without mention of intractable epilepsy Generalized convulsive epilepsy with intractable epilepsy Petit mal status Grand mal status Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, with intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, with intractable epilepsy Infantile spasms without mention of intractable epilepsy Infantile spasms with intractable epilepsy Epilepsia partialis continua without mention of intractable epilepsy Epilepsia partialis continua with intractable epilepsy Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy Other forms of epilepsy and recurrent seizures, with intractable epilepsy Unspecified epilepsy without mention of intractable epilepsy Unspecified epilepsy with intractable epilepsy Nontraumatic extradural hemorrhage Subdural hemorrhage Unspecified intracranial hemorrhage Cerebral thrombosis with cerebral infarction Cerebral embolism with cerebral infarction Unspecified cerebral artery occlusion with cerebral infarction Unspecified transient cerebral ischemia 436. Acute, but ill-defined, cerebrovascular disease Page 11

12 437.0 Cerebral atherosclerosis Other generalized ischemic cerebrovascular disease Other ill-defined cerebrovascular disease Unspecified cerebrovascular disease Cognitive deficits due to cerebrovascular disease Spina bifida with hydrocephalus, unspecified region Congenital hydrocephalus Other alteration of consciousness Other convulsions 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, no loss of consciousness Closed fracture of vault of skull without mention of intracranial injury, brief (less than one hour) loss of consciousness Closed fracture of vault of skull without mention of intracranial injury, moderate (1-24 hours) loss of consciousness Closed fracture of vault of skull without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness and return to preexisting Closed fracture of vault of skull without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of vault of skull without mention of intracranial injury, loss of consciousness of unspecified duration Closed fracture of vault of skull without mention of intracranial injury, unspecified concussion 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, no loss of consciousness Closed fracture of vault of skull with cerebral laceration and contusion, brief (less than one hour) loss of consciousness Closed fracture of vault of skull with cerebral laceration and contusion, moderate (1-24 hours) loss of consciousness Closed fracture of vault of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness and return to preexisting Closed fracture of vault of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Page 12

13 Closed fracture of vault of skull with cerebral laceration and contusion, loss of consciousness of unspecified duration Closed fracture of vault of skull with cerebral laceration and contusion, unspecified concussion 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, no loss of consciousness Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, brief (less than one hour) loss of consciousness Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, moderate (1-24 hours) loss of consciousness Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, loss of consciousness of unspecified duration Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified concussion Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, unspecified state of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, no loss of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, brief (less than one hour) loss of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, moderate (1-24 hours) loss of consciousness Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, loss of consciousness of unspecified duration Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, unspecified concussion 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, no loss of consciousness Closed fracture of vault of skull with intracranial injury of other and unspecified nature, brief (less than one hour) loss of consciousness Closed fracture of vault of skull with intracranial injury of other and unspecified nature, moderate (1-24 hours) loss of consciousness Closed fracture of vault of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Page 13

14 Closed fracture of vault of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of vault of skull with intracranial injury of other and unspecified nature, loss of consciousness of unspecified duration Closed fracture of vault of skull with intracranial injury of other and unspecified nature, unspecified concussion Open fracture of vault of skull without mention of intracranial injury, unspecified state of consciousness Open fracture of vault of skull without mention of intracranial injury, no loss of consciousness Open fracture of vault of skull without mention of intracranial injury, brief (less than one hour) loss of consciousness Open fracture of vault of skull without mention of intracranial injury, moderate (1-24 hours) loss of consciousness Open fracture of vault of skull without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness and return to preexisting Open fracture of vault of skull without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of vault of skull without mention of intracranial injury, loss of consciousness of unspecified duration Open fracture of vault of skull without mention of intracranial injury, unspecified concussion Open fracture of vault of skull with cerebral laceration and contusion, unspecified state of consciousness Open fracture of vault of skull with cerebral laceration and contusion, no loss of consciousness Open fracture of vault of skull with cerebral laceration and contusion, brief (less than one hour) loss of consciousness Open fracture of vault of skull with cerebral laceration and contusion, moderate (1-24 hours) loss of consciousness Open fracture of vault of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness and return to preexisting Open fracture of vault of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of vault of skull with cerebral laceration and contusion, loss of consciousness of unspecified duration Open fracture of vault of skull with cerebral laceration and contusion, unspecified concussion Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, no loss of consciousness Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, brief (less than one hour) loss of consciousness Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, moderate (1-24 hours) loss of consciousness Page 14

15 Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, loss of consciousness of unspecified duration Open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified concussion Open fracture of vault of skull with other and unspecified intracranial hemorrhage, unspecified state of consciousness Open fracture of vault of skull with other and unspecified intracranial hemorrhage, no loss of consciousness Open fracture of vault of skull with other and unspecified intracranial hemorrhage, brief (less than one hour) loss of consciousness Open fracture of vault of skull with other and unspecified intracranial hemorrhage, moderate (1-24 hours) loss of consciousness Open fracture of vault of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Open fracture of vault of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of vault of skull with other and unspecified intracranial hemorrhage, loss of consciousness of unspecified duration Open fracture of vault of skull with other and unspecified intracranial hemorrhage, unspecified concussion Open fracture of vault of skull with intracranial injury of other and unspecified nature, unspecified state of consciousness Open fracture of vault of skull with intracranial injury of other and unspecified nature, no loss of consciousness Open fracture of vault of skull with intracranial injury of other and unspecified nature, brief (less than one hour) loss of consciousness Open fracture of vault of skull with intracranial injury of other and unspecified nature, moderate (1-24 hours) loss of consciousness Open fracture of vault of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Open fracture of vault of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of vault of skull with intracranial injury of other and unspecified nature, loss of consciousness of unspecified duration Open fracture of vault of skull with intracranial injury of other and unspecified nature, unspecified concussion Closed fracture of base of skull without mention of intracranial injury, unspecified state of consciousness Closed fracture of base of skull without mention of intracranial injury, no loss of consciousness Page 15

16 Closed fracture of base of skull without mention of intracranial injury, brief (less than one hour) loss of consciousness Closed fracture of base of skull without mention of intracranial injury, moderate (1-24 hours) loss of consciousness Closed fracture of base of skull without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness and return to preexisting Closed fracture of base of skull without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of base of skull without mention of intracranial injury, loss of consciousness of unspecified duration Closed fracture of base of skull without mention of intracranial injury, unspecified concussion 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, no loss of consciousness Closed fracture of base of skull with cerebral laceration and contusion, brief (less than one hour) loss of consciousness Closed fracture of base of skull with cerebral laceration and contusion, moderate (1-24 hours) loss of consciousness Closed fracture of base of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness and return to preexisting Closed fracture of base of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of base of skull with cerebral laceration and contusion, loss of consciousness of unspecified duration Closed fracture of base of skull with cerebral laceration and contusion, unspecified concussion 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, no loss of consciousness Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, brief (less than one hour) loss of consciousness Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, moderate (1-24 hours) loss of consciousness Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, loss of consciousness of unspecified duration Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified concussion Page 16

17 Closed fracture of base of skull with other and unspecified intracranial hemorrhage, unspecified state of consciousness Closed fracture of base of skull with other and unspecified intracranial hemorrhage, no loss of consciousness Closed fracture of base of skull with other and unspecified intracranial hemorrhage, brief (less than one hour) loss of consciousness Closed fracture of base of skull with other and unspecified intracranial hemorrhage, moderate (1-24 hours) loss of consciousness Closed fracture of base of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Closed fracture of base of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of base of skull with other and unspecified intracranial hemorrhage, loss of consciousness of unspecified duration Closed fracture of base of skull with other and unspecified intracranial hemorrhage, unspecified concussion 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, unspecified state of consciousness Closed fracture of base of skull with intracranial injury of other and unspecified nature, brief (less than one hour) loss of consciousness Closed fracture of base of skull with intracranial injury of other and unspecified nature, moderate (1-24 hours) loss of consciousness Closed fracture of base of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Closed fracture of base of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fracture of base of skull with intracranial injury of other and unspecified nature, loss of consciousness of unspecified duration Closed fracture of base of skull with intracranial injury of other and unspecified nature, unspecified concussion Open fracture of base of skull without mention of intracranial injury, unspecified state of consciousness Open fracture of base of skull without mention of intracranial injury, no loss of consciousness Open fracture of base of skull without mention of intracranial injury, brief (less than one hour) loss of consciousness Open fracture of base of skull without mention of intracranial injury, moderate (1-24 hours) loss of consciousness Open fracture of base of skull without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness and return to preexisting Open fracture of base of skull without mention of intracranial injury, loss of consciousness of unspecified duration Open fracture of base of skull without mention of intracranial injury, unspecified concussion Page 17

18 Open fracture of base of skull with cerebral laceration and contusion, unspecified state of consciousness Open fracture of base of skull with cerebral laceration and contusion, no loss of consciousness Open fracture of base of skull with cerebral laceration and contusion, brief (less than one hour) loss of consciousness Open fracture of base of skull with cerebral laceration and contusion, moderate (1-24 hours) loss of consciousness Open fracture of base of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness and return to preexisting Open fracture of base of skull with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of base of skull with cerebral laceration and contusion, loss of consciousness of unspecified duration Open fracture of base of skull with cerebral laceration and contusion, unspecified concussion Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, no loss of consciousness Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, brief (less than one hour) loss of consciousness Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, moderate (1-24 hours) loss of consciousness Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, loss of consciousness of unspecified duration Open fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified concussion Open fracture of base of skull with other and unspecified intracranial hemorrhage, unspecified state of consciousness Open fracture of base of skull with other and unspecified intracranial hemorrhage, no loss of consciousness Open fracture of base of skull with other and unspecified intracranial hemorrhage, brief (less than one hour) loss of consciousness Open fracture of base of skull with other and unspecified intracranial hemorrhage, moderate (1-24 hours) loss of consciousness Open fracture of base of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Open fracture of base of skull with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Page 18

19 Open fracture of base of skull with other and unspecified intracranial hemorrhage, loss of consciousness of unspecified duration Open fracture of base of skull with other and unspecified intracranial hemorrhage, unspecified concussion Open fracture of base of skull with intracranial injury of other and unspecified nature, unspecified state of consciousness Open fracture of base of skull with intracranial injury of other and unspecified nature, no loss of consciousness Open fracture of base of skull with intracranial injury of other and unspecified nature, brief (less than one hour) loss of consciousness Open fracture of base of skull with intracranial injury of other and unspecified nature, moderate (1-24 hours) loss of consciousness Open fracture of base of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Open fracture of base of skull with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Open fracture of base of skull with intracranial injury of other and unspecified nature, loss of consciousness of unspecified duration Open fracture of base of skull with intracranial injury of other and unspecified nature, unspecified concussion Other closed skull fracture without mention of intracranial injury, unspecified state of consciousness Other closed skull fracture without mention of intracranial injury, no loss of consciousness Other closed skull fracture without mention of intracranial injury, brief (less than one hour) loss of consciousness Other closed skull fracture without mention of intracranial injury, moderate (1-24 hours) loss of consciousness Other closed skull fracture without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness and return to preexisting Other closed skull fracture without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other closed skull fracture without mention of intracranial injury, loss of consciousness of unspecified duration Other closed skull fracture without mention of intracranial injury, unspecified concussion Other closed skull fracture with cerebral laceration and contusion, unspecified state of consciousness Other closed skull fracture with cerebral laceration and contusion, no loss of consciousness Other closed skull fracture with cerebral laceration and contusion, brief (less than one hour) loss of consciousness Other closed skull fracture with cerebral laceration and contusion, moderate (1-24 hours) loss of consciousness Other closed skull fracture with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness and return to preexisting Page 19

20 Other closed skull fracture with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other closed skull fracture with cerebral laceration and contusion, loss of consciousness of unspecified duration Other closed skull fracture with cerebral laceration and contusion, unspecified concussion Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, no loss of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, brief (less than one hour) loss of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, moderate (1-24 hours) loss of consciousness Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, loss of consciousness of unspecified duration Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, unspecified concussion Other closed skull fracture with other and unspecified intracranial hemorrhage, unspecified state of unconsciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, no loss of consciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, brief (less than one hour) loss of consciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, moderate (1-24 hours) loss of consciousness Other closed skull fracture with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Other closed skull fracture with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other closed skull fracture with other and unspecified intracranial hemorrhage, loss of consciousness of unspecified duration Other closed skull fracture with other and unspecified intracranial hemorrhage, unspecified concussion 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, no loss of consciousness Other closed skull fracture with intracranial injury of other and unspecified nature, brief (less than one hour) loss of consciousness Other closed skull fracture with intracranial injury of other and unspecified nature, moderate (1-24 hours) loss of consciousness Page 20

21 Other closed skull fracture with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Other closed skull fracture with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other closed skull fracture with intracranial injury of other and unspecified nature, loss of consciousness of unspecified duration Other closed skull fracture with intracranial injury of other and unspecified nature, unspecified concussion Other open skull fracture without mention of injury, state of consciousness unspecified Other open skull fracture without mention of intracranial injury, no loss of consciousness Other open skull fracture without mention of intracranial injury, brief (less than one hour) loss of consciousness Other open skull fracture without mention of intracranial injury, moderate (1-24 hours) loss of consciousness Other open skull fracture without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Other open skull fracture without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other open skull fracture without mention of intracranial injury, loss of consciousness of unspecified duration Other open skull fracture without mention of intracranial injury, unspecified concussion Other open skull fracture with cerebral laceration and contusion, unspecified state of consciousness Other open skull fracture with cerebral laceration and contusion, no loss of consciousness Other open skull fracture with cerebral laceration and contusion, brief (less than one hour) loss of consciousness Other open skull fracture with cerebral laceration and contusion, moderate (1-24 hours) loss of consciousness Other open skull fracture with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness and return to preexisting Other open skull fracture with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other open skull fracture with cerebral laceration and contusion, loss of consciousness of unspecified duration Other open skull fracture with cerebral laceration and contusion, unspecified concussion Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, no loss of consciousness Page 21

22 Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, brief (less than one hour) loss of consciousness Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, moderate (1-24 hours) loss of consciousness Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, loss of consciousness of unspecified duration Other open skull fracture with subarachnoid, subdural, and extradural hemorrhage, unspecified concussion Other open skull fracture with other and unspecified intracranial hemorrhage, unspecified state of consciousness Other open skull fracture with other and unspecified intracranial hemorrhage, no loss of consciousness Other open skull fracture with other and unspecified intracranial hemorrhage, brief (less than one hour) loss of consciousness Other open skull fracture with other and unspecified intracranial hemorrhage, moderate (1-24 hours) loss of consciousness Other open skull fracture with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Other open skull fracture with other and unspecified intracranial hemorrhage, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other open skull fracture with other and unspecified intracranial hemorrhage, loss of consciousness of unspecified duration Other open skull fracture with other and unspecified intracranial hemorrhage, unspecified concussion Other open skull fracture with intracranial injury of other and unspecified nature, unspecified state of consciousness Other open skull fracture with intracranial injury of other and unspecified nature, no loss of consciousness Other open skull fracture with intracranial injury of other and unspecified nature, brief (less than one hour) loss of consciousness Other open skull fracture with intracranial injury of other and unspecified nature, moderate (1-24 hours) loss of consciousness Other open skull fracture with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Other open skull fracture with intracranial injury of other and unspecified nature, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Other open skull fracture with intracranial injury of other and unspecified nature, loss of consciousness of unspecified duration Other open skull fracture with intracranial injury of other and unspecified nature, unspecified concussion Page 22

23 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, no loss of consciousness Closed fractures involving skull or face with other bones, without mention of intracranial injury, brief (less than one hour) loss of consciousness Closed fractures involving skull or face with other bones, without mention of intracranial injury, moderate (1-24 hours) loss of consciousness Closed fractures involving skull or face with other bones, without mention or intracranial injury, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Closed fractures involving skull of face with other bones, without mention of intracranial injury, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fractures involving skull of face with other bones, without mention of intracranial injury, loss of consciousness of unspecified duration Closed fractures involving skull of face with other bones, without mention of intracranial injury, unspecified concussion 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, no loss of consciousness Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, brief (less than one hour) loss of consciousness Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, moderate (1-24 hours) loss of consciousness Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, prolonged (more than 24 hours) loss of consciousness, without return to pre-existing Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, loss of consciousness of unspecified duration Closed fractures involving skull or face with other bones, with cerebral laceration and contusion, unspecified concussion Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, no loss of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, brief (less than one hour) loss of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, moderate (1-24 hours) loss of consciousness Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, prolonged (more than 24 hours) loss of consciousness and return to pre-existing Page 23