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
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
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. 2007 Mar;21(2):209-31. [Website]: http://www.informaworld.com/smpp/content~db=all?content=10.1080/1382558060102 5932. Accessed September 16, 2013. Malik A, McDonald D. Neuropsychological Evaluation. Last updated April 2, 2013. emedicine [Website]: http://www.emedicine.com/pmr/topic149.htm. Accessed September 16, 2013. 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):1095-1104. 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. 2009. Page 3
Randolph, C, Hilsabeck, R, Kato, A, et al. Neuropsychological assessment of hepatic encephalopathy: ISHEN practice guidelines. Liver Int. 2009. Sartori E,Edan G. Assessment of cognitive dysfunction in multiple sclerosis. J Neurol Sci. 2006;245(1-2):169-75. Shadlen MF, Larson E. Evaluation of cognitive impairment and dementia. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated August 30, 2013. [Website]: www.uptodate.com. Accessed September 16, 2013. 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 96116 96118 96119 96120 Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. 090.40 Unspecified juvenile neurosyphilis 094.82 Syphilitic parkinsonism 191.0 Malignant neoplasm of cerebrum, except lobes and ventricles 191.1 Malignant neoplasm of frontal lobe 191.2 Malignant neoplasm temporal lobe 191.3 Malignant neoplasm of parietal lobe 191.4 Malignant neoplasm of occipital lobe 191.5 Malignant neoplasm of ventricles 191.6 Malignant neoplasm of cerebellum 191.7 Malignant neoplasm of brain stem Page 4
191.9 Malignant neoplasm of brain, unspecified site 192.0 Malignant neoplasm of cranial nerves 192.1 Malignant neoplasm of cerebral meninges 198.3 Secondary malignant neoplasm of brain and spinal cord 237.5 Neoplasm of uncertain behavior of brain and spinal cord 239.6 Neoplasm of uncertain nature of brain 290.0 Senile dementia, uncomplicated 290.3 Senile dementia with delirium 290.8 Other specified senile psychotic conditions 290.9 Unspecified senile psychotic condition 290.10 Presenile dementia, uncomplicated 290.11 Presenile dementia with delirium 290.12 Presenile dementia with delusional features 290.13 Presenile dementia with depressive features 290.20 Senile dementia with delusional features 290.21 Senile dementia with depressive features 290.3 Senile dementia with delirium 290.40 Vascular dementia, uncomplicated 290.41 Vascular dementia, with delirium 290.42 Vascular dementia, with delusions 290.43 Vascular dementia, with depressed mood 291.1 Alcohol-induced persisting amnestic disorder 291.5 Alcohol-induced psychotic disorder with delusions 291.81 Alcohol withdrawal 291.9 Unspecified alcohol-induced mental disorders Page 5
292.0 Drug withdrawal 292.11 Drug-induced psychotic disorder with delusions 292.82 Drug-induced persisting dementia 292.83 Drug-induced persisting amnestic disorder 292.84 Drug-induced mood disorder 292.89 Other specified drug-induced mental disorder 292.9 Unspecified drug-induced mental disorder 293.0 Delirium due to conditions classified elsewhere 293.1 Subacute delirium 293.81 Psychotic disorder with delusions in conditions classified elsewhere 293.82 Psychotic disorder with hallucinations in conditions classified elsewhere 293.83 Mood disorder in conditions classified elsewhere 293.84 Anxiety disorder in conditions classified elsewhere 293.89 Other transient mental disorders due to conditions classified elsewhere 293.9 Unspecified transient mental disorder in conditions classified elsewhere 294.0 Amnestic disorder in conditions classified elsewhere 294.1 Dementia in conditions classified elsewhere 294.8 Other persistent mental disorders due to conditions classified elsewhere 294.10 Dementia in conditions classified elsewhere without behavioral disturbance 294.11 Dementia in conditions classified elsewhere with behavioral disturbance 294.20 Dementia, unspecified, without behavioral disturbance 294.8 Other persistent mental disorders due to conditions classified elsewhere 294.9 Unspecified persistent mental disorders due to conditions classified elsewhere 295.10 Disorganized schizophrenia, unspecified condition 295.20 Catatonic schizophrenia, unspecified condition Page 6
295.30 Paranoid schizophrenia, unspecified condition 295.40 Schizophreniform disorder, unspecified 295.65 Schizophrenic disorders, residual type, in remission 295.70 Schizoaffective disorder, unspecified 295.90 Unspecified schizophrenia, unspecified condition 296.00 Bipolar i disorder, single manic episode, unspecified 296.10 Manic disorder, recurrent episode, unspecified 296.20 Major depressive disorder, single episode, unspecified 296.30 Major depressive disorder, recurrent episode, unspecified 296.40 Bipolar i disorder, most recent episode (or current) manic, unspecified 296.60 Bipolar i disorder, most recent episode (or current) mixed, unspecified 296.7 Bipolar i disorder, most recent episode (or current) unspecified 296.80 Bipolar disorder, unspecified 296.81 Atypical manic disorder 296.82 Atypical depressive disorder 296.89 Other and unspecified bipolar disorders 296.90 Unspecified episodic mood disorder 297.1 Delusional disorder 297.3 Shared psychotic disorder 298.8 Other and unspecified reactive psychosis 298.9 Unspecified psychosis 299.00 Autistic disorder, current or active state 299.10 Childhood disintegrative disorder, current or active state 299.80 Other specified pervasive developmental disorders, current or active state 300.01 Panic disorder without agoraphobia Page 7
300.02 Generalized anxiety disorder 300.11 Conversion disorder 300.19 Other and unspecified factitious illness 300.21 Agoraphobia with panic disorder 300.29 Other isolated or specific phobias 300.3 Obsessive-compulsive disorders 300.4 Dysthymic disorder 300.6 Depersonalization disorder 300.7 Hypochondriasis 300.82 Undifferentiated somatoform disorder 302.70 Psychosexual dysfunction, unspecified 302.79 Psychosexual dysfunction with other specified psychosexual dysfunctions 303.90 Other and unspecified alcohol dependence, unspecified drunkenness 304.00 Opioid type dependence, unspecified abuse 305.20 Nondependent cannabis abuse, unspecified 307.1 Anorexia nervosa 307.20 Tic disorder, unspecified 307.3 Stereotypic movement disorder 307.42 Persistent disorder of initiating or maintaining sleep 307.44 Persistent disorder of initiating or maintaining wakefulness 307.46 Sleep arousal disorder 307.50 Eating disorder, unspecified 307.59 Other disorder of eating 307.80 Psychogenic pain, site unspecified 307.89 Other pain disorder related to psychological factors Page 8
308.3 Other acute reactions to stress 309.0 Adjustment disorder with depressed mood 309.1 Prolonged depressive reaction as adjustment reaction 309.21 Separation anxiety disorder 309.23 Specific academic or work inhibition as adjustment reaction 309.24 Adjustment disorder with anxiety 309.28 Adjustment disorder with mixed anxiety and depressed mood 309.3 Adjustment disorder with disturbance of conduct 309.4 Adjustment disorder with mixed disburbance of emotions and conduct 309.81 Posttraumatic stress disorder 310.1 Personality change due to conditions classified elsewhere 311. Depressive disorder, not elsewhere classified 312.81 Conduct disorder, childhood onset type 312.82 Conduct disorder, adolescent onset type 312.89 Other specified disturbance of conduct, not elsewhere classified 313.23 Selective mutism 313.81 Oppositional defiant disorder 313.82 Identity disorder of childhood or adolescence 314.00 Attention deficit disorder of childhood without mention of hyperactivity 314.01 Attention deficit disorder of childhood with hyperactivity 314.1 Hyperkinesis of childhood with developmental delay 314.2 Hyperkinetic conduct disorder of childhood 314.8 Other specified manifestations of hyperkinetic syndrome of childhood 314.9 Unspecified hyperkinetic syndrome of childhood 315.00 Developmental reading disorder, unspecified Page 9
315.09 Other specific developmental reading disorder 315.1 Mathematics disorder 315.2 Other specific developmental learning difficulties 315.31 Expressive language disorder 315.32 Mixed receptive-expressive language disorder 315.39 Other developmental speech or language disorder 315.4 Developmental coordination disorder 315.5 Mixed development disorder 315.8 Other specified delay in development 315.9 Unspecified delay in development 317. Mild mental retardation 318.0 Moderate mental retardation 318.1 Severe mental retardation 331.0 Alzheimer's disease 331.3 Communicating hydrocephalus 331.4 Obstructive hydrocephalus 331.5 Idiopathic normal pressure hydrocephalus [INPH] 331.7 Cerebral degeneration in diseases classified elsewhere 331.19 Other frontotemporal dementia 332.0 Paralysis agitans 333.90 Unspecified extrapyramidal disease and abnormal movement disorder 333.92 Neuroleptic malignant syndrome 333.99 Other extrapyramidal disease and abnormal movement disorder 340 Multiple sclerosis 345.00 Generalized nonconvulsive epilepsy without mention of intractable epilepsy Page 10
345.01 Generalized nonconvulsive epilepsy with intractable epilepsy 345.10 Generalized convulsive epilepsy without mention of intractable epilepsy 345.11 Generalized convulsive epilepsy with intractable epilepsy 345.2 Petit mal status 345.3 Grand mal status 345.40 345.41 345.50 345.51 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 345.60 Infantile spasms without mention of intractable epilepsy 345.61 Infantile spasms with intractable epilepsy 345.70 Epilepsia partialis continua without mention of intractable epilepsy 345.71 Epilepsia partialis continua with intractable epilepsy 345.80 Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy 345.81 Other forms of epilepsy and recurrent seizures, with intractable epilepsy 345.90 Unspecified epilepsy without mention of intractable epilepsy 345.91 Unspecified epilepsy with intractable epilepsy 432.0 Nontraumatic extradural hemorrhage 432.1 Subdural hemorrhage 432.9 Unspecified intracranial hemorrhage 434.01 Cerebral thrombosis with cerebral infarction 434.11 Cerebral embolism with cerebral infarction 434.91 Unspecified cerebral artery occlusion with cerebral infarction 435.9 Unspecified transient cerebral ischemia 436. Acute, but ill-defined, cerebrovascular disease Page 11
437.0 Cerebral atherosclerosis 437.1 Other generalized ischemic cerebrovascular disease 437.8 Other ill-defined cerebrovascular disease 437.9 Unspecified cerebrovascular disease 438.0 Cognitive deficits due to cerebrovascular disease 741.00 Spina bifida with hydrocephalus, unspecified region 742.3 Congenital hydrocephalus 780.09 Other alteration of consciousness 780.39 Other convulsions 800.00 800.01 800.02 800.03 800.04 800.05 800.06 800.09 800.10 800.11 800.12 800.13 800.14 800.15 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
800.16 800.19 800.20 800.21 800.22 800.23 800.24 800.25 800.26 800.29 800.30 800.31 800.32 800.33 800.34 800.35 800.36 800.39 800.40 800.41 800.42 800.43 800.44 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
800.45 800.46 800.49 800.50 800.51 800.52 800.53 800.54 800.55 800.56 800.59 800.60 800.61 800.62 800.63 800.64 800.65 800.66 800.69 800.70 800.71 800.72 800.73 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
800.74 800.75 800.76 800.79 800.80 800.81 800.82 800.83 800.84 800.85 800.86 800.89 800.90 800.91 800.92 800.93 800.94 800.95 800.96 800.99 801.00 801.01 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
801.02 801.03 801.04 801.05 801.06 801.09 801.10 801.11 801.12 801.13 801.14 801.15 801.16 801.19 801.20 801.21 801.22 801.23 801.24 801.25 801.26 801.29 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
801.30 801.31 801.32 801.33 801.34 801.35 801.36 801.39 801.40 801.41 801.42 801.43 801.44 801.45 801.46 801.49 801.50 801.51 801.52 801.53 801.54 801.56 801.59 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
801.60 801.61 801.62 801.63 801.64 801.65 801.66 801.69 801.70 801.71 801.72 801.73 801.74 801.75 801.76 801.79 801.80 801.81 801.82 801.83 801.84 801.85 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
801.86 801.89 801.90 801.91 801.92 801.93 801.94 801.95 801.96 801.99 803.00 803.01 803.02 803.03 803.04 803.05 803.06 803.09 803.10 803.11 803.12 803.13 803.14 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
803.15 803.16 803.19 803.20 803.21 803.22 803.23 803.24 803.25 803.26 803.29 803.30 803.31 803.32 803.33 803.34 803.35 803.36 803.39 803.40 803.41 803.42 803.43 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
803.44 803.45 803.46 803.49 803.50 803.51 803.52 803.53 803.54 803.55 803.56 803.59 803.60 803.61 803.62 803.63 803.64 803.65 803.66 803.69 803.70 803.71 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
803.72 803.73 803.74 803.75 803.76 803.79 803.80 803.81 803.82 803.83 803.84 803.85 803.86 803.89 803.90 803.91 803.92 803.93 803.94 803.95 803.96 803.99 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
804.00 804.01 804.02 804.03 804.04 804.05 804.06 804.09 804.10 804.11 804.12 804.13 804.14 804.15 804.16 804.19 804.20 804.21 804.22 804.23 804.24 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