Download Emergency Department Utilization of CT for Minor Blunt Head Trauma

ACEP DRAFT Quality Measures for Public Comment
Obsolete After: October 17, 2014
Page 6 of 23
For Public Commnet: ACEP Draft Quality Measures
Measure #1: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients
Aged 18 Years and Older
For this measure higher score indicates higher quality
Measure Description
Percentage of emergency department visits for patients aged 18 years and older who presented within 24
hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT
for trauma ordered by an emergency care provider who have an indication for a head CT
Measure Components
Numerator
Statement
Denominator emergency department visits for patients who have an indication for a
head CT
Indications for a head CT in patients presenting to the emergency department for
minor blunt head trauma:
Patients with any one of the following:
 Severe headache
 Vomiting
 Age 65 years and older
 Physical signs of a basilar skull fracture (signs include haemotympanum,
“panda” eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
 Focal neurological deficit
 Coagulopathy
 Thrombocytopenia
 Currently taking any of the following anticoagulant medications:
apixaban, argatroban, bivalirudin, dabigatran, dalteparin, desirudin,
enoxaparinm fondaparinux, heparin, lepirudin, low molecular weight
heparin, rivaroxaban, tinzaparin, warfarin
 Dangerous Mechanism (ie, ejection from a motor vehicle, a pedestrian
struck, and a fall from a height of more than 3 feet or 5 stairs)
OR
Patients with either loss of consciousness OR posttraumatic amnesia AND any one
of the following:
 Headache
 Age 60 years and older, and less than 65 years
 Drug/alcohol intoxication
 Short-term memory deficits
 Evidence of trauma above the clavicles (physical location, any trauma to the
head or neck [ie, laceration, abrasion, bruising, ecchymosis, hematoma,
swelling, fracture])
 Posttraumatic seizure
©2014. American College of Emergency Physicians. All Rights Reserved.
CPT Copyright 2004-2014 American Medical Association.
Submit Comments at www.acep.org/quality/qmtep
ACEP DRAFT Quality Measures for Public Comment
Obsolete After: October 17, 2014
Page 7 of 23
Denominator
Statement
All emergency department visits for patients aged 18 years and older who presented
within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS)
score of 15 and who had a head CT for trauma ordered by an emergency care
provider
Definition:
Presented within 24 hours - The 24 hour timeframe is based on the time of injury
reported by the patient or caregiver or guardian.
Denominator note: Minor blunt head trauma includes only non-penetrating injuries.
Denominator
Exclusions
Patients with any of the following:
 Ventricular shunt
 Brain tumor
 Multisystem trauma
 Pregnancy
 Currently taking any of the following antiplatelet medications:
 ASA/dipyridamole
 clopidogrel
 prasugrel
 ticlopidine
Denominator
Exceptions
None
Rationale for the
Measure
This measure is needed to close the gap in provider performance as patients with
mild closed head injuries without guideline indications for CT or MRI imaging are
receiving such studies. The results of this are increased healthcare expenditures,
unnecessary patient radiation exposure, and possibly prolonged evaluation times.
This measure is an appropriateness measure, and as such is one for which a higher
score indicates higher quality. The technical expert panel (TEP) considered an
alternate measure construction, such that this measure would more closely match the
pediatric measure; however, the feasibility issues posed by the alternate construction
resulted in the construction as seen here.
Supporting
Guideline &
Other Evidence
The following evidence statements are quoted verbatim from the referenced clinical
guidelines and other references:
Level A recommendations. A noncontrast head CT is indicated in head trauma
patients with loss of consciousness or posttraumatic amnesia only if one or more of
the following is present: headache, vomiting, age greater than 60 years, drug or
alcohol intoxication, deficits in short-term memory, physical evidence of trauma
above the clavicle, posttraumatic seizure, GCS score less than 15, focal neurologic
deficit, or coagulopathy (ACEP, 2008).i
Level B recommendations. A noncontrast head CT should be considered in head
trauma patients with no loss of consciousness or posttraumatic amnesia if there is a
focal neurologic deficit, vomiting, severe headache, age 65 years or greater, physical
signs of a basilar skull fracture, GCS score less than 15, coagulopathy, or a
dangerous mechanism of injury.* *Dangerous mechanism of injury includes ejection
©2014. American College of Emergency Physicians. All Rights Reserved.
CPT Copyright 2004-2014 American Medical Association.
Submit Comments at www.acep.org/quality/qmtep
ACEP DRAFT Quality Measures for Public Comment
Obsolete After: October 17, 2014
Page 8 of 23
from a motor vehicle, a pedestrian struck, and a fall from a height of more than 3 feet
or 5 stairs (ACEP, 2008).ii
Measure Importance
Relationship to
desired outcome
Though it is difficult to directly attribute the effects of smaller dosages of radiation,
such as that received through computed tomography (CT), the dosage of radiation
from CTs has increased in recent years, in part due to the increased speed of image
acquisition. Additionally, there is evidence to suggest that the radiation doses from
CTs are higher and more variable than generally quoted.iii Further, as “radiation
doses associated with commonly used CT examinations resemble doses received by
individuals in whom an increased risk of cancer was documented, iv” the use of some
CT scans is associated with a “nonnegligible” lifetime attributable risk of cancer.v vi
As over 1.3 million individuals are treated and released from the ED for mild
traumatic brain injury annuallyvii, it is critical that CT scans only be utilized when
clinically appropriate. Through measurement of the share of CT scans that are
performed inappropriately, a focus can be brought to quality improvement and
increased application of clinical decision tools around this topic.
Opportunity for
Improvement
About 2.5 million traumatic brain injuries occur each year, where 75% of these are
considered mild.viii There is data to suggest that 70% of head injury patients receive a
head CTix, and it is estimated that 10-35% of head CTs obtained in head injury
patients do not follow recognized guidelines.x Some estimate that as many as
55,000-194,000 CT scans are possibly avoidable annually.xi
Exception
Justification
The ACEP Measure Work Group agreed to include appropriate medical reasons as an
exception so that clinicians can exclude patients for whom CT imaging may be
justified.
Harmonization with Staff has considered harmonization with NQF 0668 – Appropriate Head CT Imaging
in Adults with Mild Traumatic Brain Injury.
Existing Measures
Measure Designation
Measure purpose
(check all that apply)
Type of measure
National Quality
Strategy
Priority/CMS
Measure Domain
(check all that apply)






☒ Quality improvement
☒ Accountability
☒ MOC
☒ Process
☐ Outcome
☐ Structure







☐ Clinical Process-Effectiveness
☐ Patient Safety
☐ Patient Experience
☐ Care Coordination
☒ Efficiency: Overuse
☐ Efficiency: Cost
☐ Population & Community Health
©2014. American College of Emergency Physicians. All Rights Reserved.
CPT Copyright 2004-2014 American Medical Association.
Submit Comments at www.acep.org/quality/qmtep
ACEP DRAFT Quality Measures for Public Comment
Obsolete After: October 17, 2014
Page 9 of 23
Level of
Measurement
(check all that apply)
Care setting
(check all that apply)
Data source
(check all that apply)










☒ Individual clinicians
☒ Clinician groups
☒ Hospital Outpatient/ED
☒ Emergency Departments
☒ Urgent Care
☐ Harmonize with other care settings
o ☐ Physician Office Based Measures
o ☐ Hospital Level Measure
☒ Electronic health record (EHR) data
☒ Administrative Data/Claims (inpatient, outpatient or multiple-source
claims)
☒ Paper medical record/Chart abstracted
☒ Registry
©2014. American College of Emergency Physicians. All Rights Reserved.
CPT Copyright 2004-2014 American Medical Association.
Submit Comments at www.acep.org/quality/qmtep
American College of Emergency Physicians (ACEP)
Data Requirements Table
Measure #1: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Measure
Component
Supplemental
Data Elements
Initial
Population
QDM* Standard Category
QDM* Data Type
Value Set Name
Individual Characteristic
Patient Characteristic
ONC Administrative Sex
Individual Characteristic
Patient Characteristic
Race
Individual Characteristic
Patient Characteristic
Ethnicity
Individual Characteristic
Patient Characteristic
Payer
Measure Timing
n/a
Individual Characteristic
Patient Characteristic
age
Measurement Period
Encounter
Encounter, Performed
Emergency Department Visit,
Occurrence A
Condition / Diagnosis / Problem
Diagnosis, Active
Non-Penetrating Head Trauma,
Occurrence A
Standard Terminology
OID
Constraints
Administrative Sex (HL7 v2.5)
2.16.840.1.113762.1.4.1
during measurement period
CDC
2.16.840.1.114222.4.11.836
during measurement period
CDC
2.16.840.1.114222.4.11.837
during measurement period
Source of Payment Typology
2.16.840.1.113883.221.5
during measurement period
Comments/Rationale
This data element is collected for the purpose of stratifying results in an effort
to highlight disparities.
This data element is collected for the purpose of stratifying results in an effort
to highlight disparities.
This data element is collected for the purpose of stratifying results in an effort
to highlight disparities.
This data element is collected for the purpose of stratifying results in an effort
to highlight disparities.
n/a
n/a
TBD by Measure Implementer
Calculation
n/a
>= 18 years AT measurement period
GROUPING
CPT
SNOMED-CT
GROUPING
ICD-9-CM
ICD-10-CM
SNOMED-CT
TBD
2.16.840.1.113883.3.464.1003.101.11.1050
2.16.840.1.113883.3.117.1.7.1.292
during measurement period
TBD
Measurement start date minus Birth Date must be greater than or equal to
18 years.
<= 24 hours starts before start of [Occurrence A of The timing of this data element is reported by the patient or the patient's
Encounter, Performed: Emergency Department Visit] caregiver.
Equals Initial Population
GROUPING
Risk Category Assessment
Risk Category Assessment Glasgow Coma Scale
TBD
LOINC
during [Occurrence A of Encounter, Performed:
Emergency Department Visit]
Denominator
Attribute
Attribute: Result
= 15
n/a
n/a
n/a
TBD
during [Occurrence A of Encounter, Performed:
Emergency Department Visit]
TBD
overlaps [Occurrence A of Encounter, Performed:
Emergency Department Visit]
TBD
during [Occurrence A of Encounter, Performed:
Emergency Department Visit]
This value set will include LOINC concepts for CT scans of the chest, pelvis
and spine (excluding cervical spine), and abdomen.
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
In order to capture 'multisystem trauma' as identified in the measure
language, we will require that at least two trauma codes be included in the
patient's medical record. One of those codes will be a head trauma code
which is captured in the Denominator; the other will be within this value set.
This value set excludes all trauma codes pertaining to the head in order to try
to identify traumas elsewhere on the patient that would indicate multisystem
trauma.
2.16.840.1.113883.3.526.3.378
2.16.840.1.113883.3.526.2.243
2.16.840.1.113883.3.526.2.242
2.16.840.1.113883.3.526.2.532
overlaps [Occurrence A of Encounter, Performed:
Emergency Department Visit]
TBD
overlaps [Occurrence A of Encounter, Performed:
Emergency Department Visit]
GROUPING
Diagnostic Study
Diagnostic Study, Order
Head CT
LOINC
Condition / Diagnosis / Problem
Diagnosis, Active
Diagnostic Study
Diagnostic Study, Order
Ventricular Shunt
GROUPING
ICD-9-CM
ICD-10-CM
SNOMED-CT
GROUPING
CT of Torso
This attribute is applied to the data element 'Glasgow Coma Scale'.
To meet this data element, an emergency care provider must have ordered
the Head CT for trauma.
LOINC
GROUPING
Denominator
Exclusions
ICD-9-CM
Condition / Diagnosis / Problem
Diagnosis, Active
Trauma, Excluding Head
ICD-10-CM
SNOMED-CT
Condition / Diagnosis / Problem
Diagnosis, Active
Pregnancy
Medication
Medication, Active
Antiplatelet Therapy
GROUPING
ICD-9-CM
ICD-10-CM
SNOMED-CT
GROUPING
RxNORM
Quality Data Model (QDM), Version 4.1.
© 2014 American College of Emergency Physicians. All Rights Reserved.
American College of Emergency Physicians (ACEP)
Data Requirements Table
Measure #1: Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Measure
Component
QDM* Standard Category
QDM* Data Type
Individual Characteristic
Patient Characteristic
Symptom
Symptom, Active
Value Set Name
age
Standard Terminology
OID
Constraints
Calculation
n/a
>= 65 years AT [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
overlaps [Occurrence A of Encounter, Performed:
Emergency Department Visit]
TBD
overlaps [Occurrence A of Encounter, Performed:
Emergency Department Visit]
TBD
overlaps [Occurrence A of Encounter, Performed:
Emergency Department Visit]
TBD
n/a
This attribute is applied to the data element 'Non-Penetrating Head Trauma'.
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
This data element is meant to capture patient symptoms that present after
the 'Non-Penetrating Head Trauma'. However, the timestamp that would be
logged within the EHR would likely be during the emergency department
visit, even though the symptom actually became active prior to admission to
the emergency department.
n/a
>= 60 years AT [Occurrence A of Encounter,
Performed: Emergency Department Visit]
AND
< 65 years AT [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
overlaps [Occurrence A of Encounter, Performed:
Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
starts during [Occurrence A of Encounter,
Performed: Emergency Department Visit]
TBD
n/a
This attribute is applied to the data element 'Evidence of Trauma'. If there is
evidence of trauma of the head, that serves as an indication for a Head CT.
TBD
n/a
This attribute is applied to the data element 'Evidence of Trauma'. If there is
evidence of trauma of the neck that serves as an indication for a Head CT.
GROUPING
Severe Headache
SNOMED-CT
GROUPING
Symptom
Symptom, Active
Vomiting
SNOMED-CT
Symptom
Symptom, Active
Physical Signs of Basilar Skull
Fracture
GROUPING
SNOMED-CT
GROUPING
Symptom
Symptom, Active
Focal Neurological Deficit
SNOMED-CT
Comments/Rationale
Measurement start date minus Birth Date greater than 65 years.
This data element is meant to capture patient symptoms that present after
the 'Non-Penetrating Head Trauma'. However, the timestamp that would be
logged within the EHR would likely be during the emergency department
visit, even though the symptom actually became active prior to admission to
the emergency department.
GROUPING
Condition / Diagnosis / Problem
Diagnosis, Active
Coagulopathies
ICD-9-CM
ICD-10-CM
SNOMED-CT
GROUPING
Condition / Diagnosis / Problem
Diagnosis, Active
Thrombocytopenia
ICD-9-CM
ICD-10-CM
SNOMED-CT
GROUPING
Medication
Medication, Active
Anticoagulant
RXNORM
This value set is intended to be comprehensive and will contain all human
SCD prescribable anticoagulant drug concepts available in RxNorm regardless of route of administration or setting of administration.
GROUPING
Attribute
Attribute: Reason
Dangerous Mechanism of Injury
SNOMED-CT
Numerator
GROUPING
Symptom
Symptom, Active
Loss of Consciousness
SNOMED-CT
GROUPING
Symptom
Symptom, Active
Post-Traumatic Amnesia
SNOMED-CT
Individual Characteristic
Patient Characteristic
Condition / Diagnosis / Problem
Diagnosis, Active
age
Calculation
Measurement start date minus Birth Date greater than 60 years and less
than 65 years.
GROUPING
Drug or Alcohol Intoxication
ICD-9-CM
ICD-10-CM
SNOMED-CT
GROUPING
Symptom
Symptom, Active
Headache
SNOMED-CT
GROUPING
Symptom
Symptom, Active
Short-Term Memory Deficits
SNOMED-CT
GROUPING
Symptom
Symptom, Active
Seizure After Head Injury
SNOMED-CT
GROUPING
Symptom
Symptom, Active
Evidence of Trauma
SNOMED-CT
Attribute
Attribute
Denominator
Exceptions
GROUPING
Attribute: Anatomical
Location Site
Head
Attribute: Anatomical
Location Site
Neck
SNOMED-CT
GROUPING
SNOMED-CT
This data element is meant to capture patient symptoms that present after
the 'Non-Penetrating Head Trauma'. However, the timestamp that would be
logged within the EHR would likely be during the emergency department
visit, even though the symptom actually became active prior to admission to
the emergency department.
There are no valid denominator exceptions.
Quality Data Model (QDM), Version 4.1.
© 2014 American College of Emergency Physicians. All Rights Reserved.
American College of Emergency Physicians
Claims Specifications
Measure #1: Emergency Medicine: Emergency Department Utilization of CT for
Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Denominator
(Eligible
Population)
All emergency department visits for patients aged 18 years and older who presented within 24
hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a
head CT for trauma ordered by an emergency care provider
Definition:
Presented within 24 hours - The 24 hour timeframe is based on the time of injury reported by the
patient or caregiver or guardian.
Denominator note: Minor blunt head trauma includes only non-penetrating injuries.
Age >= 18 years
AND
CPT® Code for Encounter:
99281, 99282, 99283, 99284, 99285
AND
ICD-9-CM Diagnosis Code for non-penetrating head injury (reportable through 9/30/2015):
Code
Descriptor
800.00
800.01
800.02
800.03
800.06
800.09
800.10
800.11
800.12
800.13
800.16
800.19
800.20
800.21
800.22
800.23
800.26
800.29
800.30
Closed fracture of vault of skull without mention of intracranial injury, unspecified state of
consciousness
Closed fracture of vault of skull without mention of intracranial injury, with no loss of
consciousness
Closed fracture of vault of skull without mention of intracranial injury, with brief [less than
one hour] loss of consciousness
Closed fracture of vault of skull without mention of intracranial injury, with moderate [1-24
hours] loss of consciousness
Closed fracture of vault of skull without mention of intracranial injury, with loss of
consciousness of unspecified duration
Closed fracture of vault of skull without mention of intracranial injury, with concussion,
unspecified
Closed fracture of vault of skull with cerebral laceration and contusion, unspecified state of
consciousness
Closed fracture of vault of skull with cerebral laceration and contusion, with no loss of
consciousness
Closed fracture of vault of skull with cerebral laceration and contusion, with brief [less than
one hour] loss of consciousness
Closed fracture of vault of skull with cerebral laceration and contusion, with moderate [1-24
hours] loss of consciousness
Closed fracture of vault of skull with cerebral laceration and contusion, with loss of
consciousness of unspecified duration
Closed fracture of vault of skull with cerebral laceration and contusion, with concussion,
unspecified
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage,
unspecified state of consciousness
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with
no loss of consciousness
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with
brief [less than one hour] loss of consciousness
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with
moderate [1-24 hours] loss of consciousness
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with
loss of consciousness of unspecified duration
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with
concussion, unspecified
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage,
unspecified state of consciousness
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
800.31
800.32
800.33
800.36
800.39
800.40
800.41
800.42
800.43
800.46
800.49
801.00
801.01
801.02
801.03
801.06
801.09
801.10
801.11
801.12
801.13
801.16
801.19
801.20
801.21
801.22
801.23
801.26
801.29
801.30
801.31
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with no
loss of consciousness
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with brief
[less than one hour] loss of consciousness
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with
moderate [1-24 hours] loss of consciousness
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with loss
of consciousness of unspecified duration
Closed fracture of vault of skull with other and unspecified intracranial hemorrhage, with
concussion, unspecified
Closed fracture of vault of skull with intracranial injury of other and unspecified nature,
unspecified state of consciousness
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with
no loss of consciousness
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with
brief [less than one hour] loss of consciousness
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with
moderate [1-24 hours] loss of consciousness
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with
loss of consciousness of unspecified duration
Closed fracture of vault of skull with intracranial injury of other and unspecified nature, with
concussion, unspecified
Closed fracture of base of skull without mention of intra cranial injury, unspecified state of
consciousness
Closed fracture of base of skull without mention of intra cranial injury, with no loss of
consciousness
Closed fracture of base of skull without mention of intra cranial injury, with brief [less than
one hour] loss of consciousness
Closed fracture of base of skull without mention of intra cranial injury, with moderate [1-24
hours] loss of consciousness
Closed fracture of base of skull without mention of intra cranial injury, with loss of
consciousness of unspecified duration
Closed fracture of base of skull without mention of intra cranial injury, with concussion,
unspecified
Closed fracture of base of skull with cerebral laceration and contusion, unspecified state of
consciousness
Closed fracture of base of skull with cerebral laceration and contusion, with no loss of
consciousness
Closed fracture of base of skull with cerebral laceration and contusion, with brief [less than
one hour] loss of consciousness
Closed fracture of base of skull with cerebral laceration and contusion, with moderate [1-24
hours] loss of consciousness
Closed fracture of base of skull with cerebral laceration and contusion, with loss of
consciousness of unspecified duration
Closed fracture of base of skull with cerebral laceration and contusion, with concussion,
unspecified
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage,
unspecified state of consciousness
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with
no loss of consciousness
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with
brief [less than one hour] loss of consciousness
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with
moderate [1-24 hours] loss of consciousness
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with
loss of consciousness of unspecified duration
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with
concussion, unspecified
Closed fracture of base of skull with other and unspecified intracranial hemorrhage,
unspecified state of consciousness
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with no
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
801.32
801.33
801.36
801.39
801.40
801.41
801.42
801.43
801.46
801.49
802.0
802.20
802.21
802.22
802.23
802.24
802.25
802.26
802.27
802.28
802.29
802.4
802.6
802.8
803.00
803.01
803.02
803.03
803.06
803.09
803.10
803.11
803.12
803.13
803.16
loss of consciousness
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with brief
[less than one hour] loss of consciousness
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with
moderate [1-24 hours] loss of consciousness
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with loss
of consciousness of unspecified duration
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with
concussion, unspecified
Closed fracture of base of skull with intracranial injury of other and unspecified nature,
unspecified state of consciousness
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with
no loss of consciousness
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with
brief [less than one hour] loss of consciousness
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with
moderate [1-24 hours] loss of consciousness
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with
loss of consciousness of unspecified duration
Closed fracture of base of skull with intracranial injury of other and unspecified nature, with
concussion, unspecified
Closed fracture of nasal bones
Closed fracture of mandible, unspecified site
Closed fracture of mandible, condylar process
Closed fracture of mandible, subcondylar
Closed fracture of mandible, coronoid process
Closed fracture of mandible, ramus, unspecified
Closed fracture of mandible, angle of jaw
Closed fracture of mandible, symphysis of body
Closed fracture of mandible, alveolar border of body
Closed fracture of mandible, body, other and unspecified
Closed fracture of mandible, multiple sites
Closed fracture of malar and maxillary bones
Closed fracture of orbital floor (blow-out)
Closed fracture of other facial bones
Other closed skull fracture without mention of intracranial injury, unspecified state of
consciousness
Other closed skull fracture without mention of intracranial injury, with no loss of
consciousness
Other closed skull fracture without mention of intracranial injury, with brief [less than one
hour] loss of consciousness
Other closed skull fracture without mention of intracranial injury, with moderate [1-24 hours]
loss of consciousness
Other closed skull fracture without mention of intracranial injury, with loss of consciousness
of unspecified duration
Other closed skull fracture without mention of intracranial injury, with concussion,
unspecified
Other closed skull fracture with cerebral laceration and contusion, unspecified state of
consciousness
Other closed skull fracture with cerebral laceration and contusion, with no loss of
consciousness
Other closed skull fracture with cerebral laceration and contusion, with brief [less than one
hour] loss of consciousness
Other closed skull fracture with cerebral laceration and contusion, with moderate [1-24 hours]
loss of consciousness
Other closed skull fracture with cerebral laceration and contusion, with loss of consciousness
of unspecified duration
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
803.19
803.20
803.21
803.22
803.23
803.26
803.29
803.30
803.31
803.32
803.33
803.36
803.39
803.40
803.41
803.42
803.46
803.49
804.00
804.01
804.02
804.03
804.06
804.09
804.10
804.11
804.12
804.13
804.16
804.19
804.20
Other closed skull fracture with cerebral laceration and contusion, with concussion,
unspecified
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage,
unspecified state of consciousness
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with no
loss of consciousness
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with brief
[less than one hour] loss of consciousness
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with
moderate [1-24 hours] loss of consciousness
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with loss
of consciousness of unspecified duration
Other closed skull fracture with subarachnoid, subdural, and extradural hemorrhage, with
concussion, unspecified
Other closed skull fracture with other and unspecified intracranial hemorrhage, unspecified
state of unconsciousness
Other closed skull fracture with other and unspecified intracranial hemorrhage, with no loss of
consciousness
Other closed skull fracture with other and unspecified intracranial hemorrhage, with brief [less
than one hour] loss of consciousness
Other closed skull fracture with other and unspecified intracranial hemorrhage, with moderate
[1-24 hours] loss of consciousness
Other closed skull fracture with other and unspecified intracranial hemorrhage, with loss of
consciousness of unspecified duration
Other closed skull fracture with other and unspecified intracranial hemorrhage, with
concussion, unspecified
Other closed skull fracture with intracranial injury of other and unspecified nature,
unspecified state of consciousness
Other closed skull fracture with intracranial injury of other and unspecified nature, with no
loss of consciousness
Other closed skull fracture with intracranial injury of other and unspecified nature, with brief
[less than one hour] loss of consciousness
Other closed skull fracture with intracranial injury of other and unspecified nature, with loss
of consciousness of unspecified duration
Other closed skull fracture with intracranial injury of other and unspecified nature, with
concussion, unspecified
Closed fractures involving skull or face with other bones, without mention of intracranial
injury, unspecified state of consciousness
Closed fractures involving skull or face with other bones, without mention of intracranial
injury, with no loss of consciousness
Closed fractures involving skull or face with other bones, without mention of intracranial
injury, with brief [less than one hour] loss of consciousness
Closed fractures involving skull or face with other bones, without mention of intracranial
injury, with moderate [1-24 hours] loss of consciousness
Closed fractures involving skull of face with other bones, without mention of intracranial
injury, with loss of consciousness of unspecified duration
Closed fractures involving skull of face with other bones, without mention of intracranial
injury, with concussion, unspecified
Closed fractures involving skull or face with other bones, with cerebral laceration and
contusion, unspecified state of consciousness
Closed fractures involving skull or face with other bones, with cerebral laceration and
contusion, with no loss of consciousness
Closed fractures involving skull or face with other bones, with cerebral laceration and
contusion, with brief [less than one hour] loss of consciousness
Closed fractures involving skull or face with other bones, with cerebral laceration and
contusion, with moderate [1-24 hours] loss of consciousness
Closed fractures involving skull or face with other bones, with cerebral laceration and
contusion, with loss of consciousness of unspecified duration
Closed fractures involving skull or face with other bones, with cerebral laceration and
contusion, with concussion, unspecified
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
804.21
804.22
804.23
804.26
804.29
804.30
804.31
804.32
804.33
804.36
804.39
804.40
804.41
804.42
804.43
804.46
804.49
850.0
850.11
850.12
850.2
850.5
850.9
851.00
851.01
851.02
851.03
851.06
851.09
851.20
851.21
851.22
extradural hemorrhage, unspecified state of consciousness
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and
extradural hemorrhage, with no loss of consciousness
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and
extradural hemorrhage, with brief [less than one hour] loss of consciousness
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and
extradural hemorrhage, with moderate [1-24 hours] loss of consciousness
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and
extradural hemorrhage, with loss of consciousness of unspecified duration
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and
extradural hemorrhage, with concussion, unspecified
Closed fractures involving skull or face with other bones, with other and unspecified
intracranial hemorrhage, unspecified state of consciousness
Closed fractures involving skull or face with other bones, with other and unspecified
intracranial hemorrhage, with no loss of consciousness
Closed fractures involving skull or face with other bones, with other and unspecified
intracranial hemorrhage, with brief [less than one hour] loss of consciousness
Closed fractures involving skull or face with other bones, with other and unspecified
intracranial hemorrhage, with moderate [1-24 hours] loss of consciousness
Closed fractures involving skull or face with other bones, with other and unspecified
intracranial hemorrhage, with loss of consciousness of unspecified duration
Closed fractures involving skull or face with other bones, with other and unspecified
intracranial hemorrhage, with concussion, unspecified
Closed fractures involving skull or face with other bones, with intracranial injury of other and
unspecified nature, unspecified state of consciousness
Closed fractures involving skull or face with other bones, with intracranial injury of other and
unspecified nature, with no loss of consciousness
Closed fractures involving skull or face with other bones, with intracranial injury of other and
unspecified nature, with brief [less than one hour] loss of consciousness
Closed fractures involving skull or face with other bones, with intracranial injury of other and
unspecified nature, with moderate [1-24 hours] loss of consciousness
Closed fractures involving skull or face with other bones, with intracranial injury of other and
unspecified nature, with loss of consciousness of unspecified duration
Closed fractures involving skull or face with other bones, with intracranial injury of other and
unspecified nature, with concussion, unspecified
Concussion with no loss of consciousness
Concussion, with loss of consciousness of 30 minutes or less
Concussion, with loss of consciousness from 31 to 59 minutes
Concussion with moderate loss of consciousness
Concussion with loss of consciousness of unspecified duration
Concussion, unspecified
Cortex (cerebral) contusion without mention of open intracranial wound, unspecified state of
consciousness
Cortex (cerebral) contusion without mention of open intracranial wound, with no loss of
consciousness
Cortex (cerebral) contusion without mention of open intracranial wound, with brief [less than
one hour] loss of consciousness
Cortex (cerebral) contusion without mention of open intracranial wound, with moderate [1-24
hours] loss of consciousness
Cortex (cerebral) contusion without mention of open intracranial wound, with loss of
consciousness of unspecified duration
Cortex (cerebral) contusion without mention of open intracranial wound, with concussion,
unspecified
Cortex (cerebral) laceration without mention of open intracranial wound, unspecified state of
consciousness
Cortex (cerebral) laceration without mention of open intracranial wound, with no loss of
consciousness
Cortex (cerebral) laceration without mention of open intracranial wound, with brief [less than
one hour] loss of consciousness
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
851.23
851.26
851.29
851.40
851.41
851.42
851.43
851.46
851.49
851.60
851.61
851.62
851.63
851.66
851.69
851.80
851.81
851.82
851.83
851.86
851.89
852.00
852.01
852.02
852.03
852.06
852.09
852.20
852.21
852.22
852.23
Cortex (cerebral) laceration without mention of open intracranial wound, with moderate [1-24
hours] loss of consciousness
Cortex (cerebral) laceration without mention of open intracranial wound, with loss of
consciousness of unspecified duration
Cortex (cerebral) laceration without mention of open intracranial wound, with concussion,
unspecified
Cerebellar or brain stem contusion without mention of open intracranial wound, unspecified
state of consciousness
Cerebellar or brain stem contusion without mention of open intracranial wound, with no loss
of consciousness
Cerebellar or brain stem contusion without mention of open intracranial wound, with brief
[less than one hour] loss of consciousness
Cerebellar or brain stem contusion without mention of open intracranial wound, with
moderate [1-24 hours] loss of consciousness
Cerebellar or brain stem contusion without mention of open intracranial wound, with loss of
consciousness of unspecified duration
Cerebellar or brain stem contusion without mention of open intracranial wound, with
concussion, unspecified
Cerebellar or brain stem laceration without mention of open intracranial wound, unspecified
state of consciousness
Cerebellar or brain stem laceration without mention of open intracranial wound, with no loss
of consciousness
Cerebellar or brain stem laceration without mention of open intracranial wound, with brief
[less than 1 hour] loss of consciousness
Cerebellar or brain stem laceration without mention of open intracranial wound, with
moderate [1-24 hours] loss of consciousness
Cerebellar or brain stem laceration without mention of open intracranial wound, with loss of
consciousness of unspecified duration
Cerebellar or brain stem laceration without mention of open intracranial wound, with
concussion, unspecified
Other and unspecified cerebral laceration and contusion, without mention of open intracranial
wound, unspecified state of consciousness
Other and unspecified cerebral laceration and contusion, without mention of open intracranial
wound, with no loss of consciousness
Other and unspecified cerebral laceration and contusion, without mention of open intracranial
wound, with brief [less than one hour] loss of consciousness
Other and unspecified cerebral laceration and contusion, without mention of open intracranial
wound, with moderate [1-24 hours] loss of consciousness
Other and unspecified cerebral laceration and contusion, without mention of open intracranial
wound, with loss of consciousness of unspecified duration
Other and unspecified cerebral laceration and contusion, without mention of open intracranial
wound, with concussion, unspecified
Subarachnoid hemorrhage following injury without mention of open intracranial wound,
unspecified state of consciousness
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with
no loss of consciousness
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with
brief [less than one hour] loss of consciousness
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with
moderate [1-24 hours] loss of consciousness
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with
loss of consciousness of unspecified duration
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with
concussion, unspecified
Subdural hemorrhage following injury without mention of open intracranial wound,
unspecified state of consciousness
Subdural hemorrhage following injury without mention of open intracranial wound, with no
loss of consciousness
Subdural hemorrhage following injury without mention of open intracranial wound, with brief
[less than one hour] loss of consciousness
Subdural hemorrhage following injury without mention of open intracranial wound, with
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
852.26
852.29
852.40
852.41
852.42
852.43
852.46
852.49
853.00
853.01
853.02
853.03
853.06
853.09
854.00
854.01
854.02
854.03
854.06
854.09
920
959.01
moderate [1-24 hours] loss of consciousness
Subdural hemorrhage following injury without mention of open intracranial wound, with loss
of consciousness of unspecified duration
Subdural hemorrhage following injury without mention of open intracranial wound, with
concussion, unspecified
Extradural hemorrhage following injury without mention of open intracranial wound,
unspecified state of consciousness
Extradural hemorrhage following injury without mention of open intracranial wound, with no
loss of consciousness
Extradural hemorrhage following injury without mention of open intracranial wound, with
brief [less than 1 hour] loss of consciousness
Extradural hemorrhage following injury without mention of open intracranial wound, with
moderate [1-24 hours] loss of consciousness
Extradural hemorrhage following injury without mention of open intracranial wound, with loss
of consciousness of unspecified duration
Extradural hemorrhage following injury without mention of open intracranial wound, with
concussion, unspecified
Other and unspecified intracranial hemorrhage following injury without mention of open
intracranial wound, unspecified state of consciousness
Other and unspecified intracranial hemorrhage following injury without mention of open
intracranial wound, with no loss of consciousness
Other and unspecified intracranial hemorrhage following injury without mention of open
intracranial wound, with brief [less than one hour] loss of consciousness
Other and unspecified intracranial hemorrhage following injury without mention of open
intracranial wound, with moderate [1-24 hours] loss of consciousness
Other and unspecified intracranial hemorrhage following injury without mention of open
intracranial wound, with loss of consciousness of unspecified duration
Other and unspecified intracranial hemorrhage following injury without mention of open
intracranial wound, with concussion, unspecified
Intracranial injury of other and unspecified nature without mention of open intracranial
wound, unspecified state of consciousness
Intracranial injury of other and unspecified nature without mention of open intracranial
wound, with no loss of consciousness
Intracranial injury of other and unspecified nature without mention of open intracranial
wound, with brief [less than one hour] loss of consciousness
Intracranial injury of other and unspecified nature without mention of open intracranial
wound, with moderate [1-24 hours] loss of consciousness
Intracranial injury of other and unspecified nature without mention of open intracranial
wound, with loss of consciousness of unspecified duration
Intracranial injury of other and unspecified nature without mention of open intracranial
wound, with concussion, unspecified
Contusion of face, scalp, and neck except eye(s)
Head injury, unspecified
ICD-10-CM Diagnosis Code for non-penetrating head injury (reportable beginning 10/1/2015):
Code
Descriptor
S00.03XA Contusion of scalp, initial encounter
S00.33XA Contusion of nose, initial encounter
S00.431A Contusion of right ear, initial encounter
S00.432A Contusion of left ear, initial encounter
S00.439A Contusion of unspecified ear, initial encounter
S00.531A Contusion of lip, initial encounter
S00.532A Contusion of oral cavity, initial encounter
S00.83XA Contusion of other part of head, initial encounter
S00.93XA Contusion of unspecified part of head, initial encounter
S02.0XXA Fracture of vault of skull, initial encounter for closed fracture
S02.10XA Unspecified fracture of base of skull, initial encounter for closed fracture
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
S02.110A
S02.111A
S02.112A
S02.113A
S02.118A
S02.119A
S02.19XA
S02.2XXA
S02.3XXA
S02.400A
S02.401A
S02.402A
S02.411A
S02.412A
S02.413A
S02.42XA
S02.600A
S02.609A
S02.61XA
S02.62XA
S02.63XA
S02.64XA
S02.65XA
S02.66XA
S02.67XA
S02.69XA
S02.8XXA
S02.91XA
S02.92XA
S06.0X0A
S06.0X1A
S06.0X2A
S06.0X3A
S06.0X4A
S06.0X9A
S06.1X0A
S06.1X1A
S06.1X2A
S06.1X3A
S06.1X4A
S06.1X9A
S06.2X0A
S06.2X1A
S06.2X2A
S06.2X3A
Type I occipital condyle fracture, initial encounter for closed fracture
Type II occipital condyle fracture, initial encounter for closed fracture
Type III occipital condyle fracture, initial encounter for closed fracture
Unspecified occipital condyle fracture, initial encounter for closed fracture
Other fracture of occiput, initial encounter for closed fracture
Unspecified fracture of occiput, initial encounter for closed fracture
Other fracture of base of skull, initial encounter for closed fracture
Fracture of nasal bones, initial encounter for closed fracture
Fracture of orbital floor, initial encounter for closed fracture
Malar fracture unspecified, initial encounter for closed fracture
Maxillary fracture, unspecified, initial encounter for closed fracture
Zygomatic fracture, unspecified, initial encounter for closed fracture
LeFort I fracture, initial encounter for closed fracture
LeFort II fracture, initial encounter for closed fracture
LeFort III fracture, initial encounter for closed fracture
Fracture of alveolus of maxilla, initial encounter for closed fracture
Fracture of unspecified part of body of mandible, initial encounter for closed fracture
Fracture of mandible, unspecified, initial encounter for closed fracture
Fracture of condylar process of mandible, initial encounter for closed fracture
Fracture of subcondylar process of mandible, initial encounter for closed fracture
Fracture of coronoid process of mandible, initial encounter for closed fracture
Fracture of ramus of mandible, initial encounter for closed fracture
Fracture of angle of mandible, initial encounter for closed fracture
Fracture of symphysis of mandible, initial encounter for closed fracture
Fracture of alveolus of mandible, initial encounter for closed fracture
Fracture of mandible of other specified site, initial encounter for closed fracture
Fractures of other specified skull and facial bones, initial encounter for closed fracture
Unspecified fracture of skull, initial encounter for closed fracture
Unspecified fracture of facial bones, initial encounter for closed fracture
Concussion without loss of consciousness, initial encounter
Concussion with loss of consciousness of 30 minutes or less, initial encounter
Concussion with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Concussion with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Concussion with loss of consciousness of 6 hours to 24 hours, initial encounter
Concussion with loss of consciousness of unspecified duration, initial encounter
Traumatic cerebral edema without loss of consciousness, initial encounter
Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter
Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, initial
encounter
Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, initial
encounter
Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, initial
encounter
Traumatic cerebral edema with loss of consciousness of unspecified duration, initial
encounter
Diffuse traumatic brain injury without loss of consciousness, initial encounter
Diffuse traumatic brain injury with loss of consciousness of 30 minutes or less, initial
encounter
Diffuse traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, initial
encounter
Diffuse traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes,
initial encounter
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
S06.2X4A
S06.2X9A
S06.300A
S06.301A
S06.302A
S06.303A
S06.304A
S06.309A
S06.310A
S06.311A
S06.312A
S06.313A
S06.314A
S06.319A
S06.320A
S06.321A
S06.322A
S06.323A
S06.324A
S06.329A
S06.330A
S06.331A
S06.332A
S06.333A
S06.334A
S06.339A
S06.340A
S06.341A
S06.342A
S06.343A
S06.344A
S06.349A
Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours, initial
encounter
Diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial
encounter
Unspecified focal traumatic brain injury without loss of consciousness, initial encounter
Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less,
initial encounter
Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59
minutes, initial encounter
Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59
minutes, initial encounter
Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours,
initial encounter
Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration,
initial encounter
Contusion and laceration of right cerebrum without loss of consciousness, initial encounter
Contusion and laceration of right cerebrum with loss of consciousness of 30 minutes or less,
initial encounter
Contusion and laceration of right cerebrum with loss of consciousness of 31 minutes to 59
minutes, initial encounter
Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours
59 minutes, initial encounter
Contusion and laceration of right cerebrum with loss of consciousness of 6 hours to 24
hours, initial encounter
Contusion and laceration of right cerebrum with loss of consciousness of unspecified
duration, initial encounter
Contusion and laceration of left cerebrum without loss of consciousness, initial encounter
Contusion and laceration of left cerebrum with loss of consciousness of 30 minutes or less,
initial encounter
Contusion and laceration of left cerebrum with loss of consciousness of 31 minutes to 59
minutes, initial encounter
Contusion and laceration of left cerebrum with loss of consciousness of 1 hour to 5 hours 59
minutes, initial encounter
Contusion and laceration of left cerebrum with loss of consciousness of 6 hours to 24 hours,
initial encounter
Contusion and laceration of left cerebrum with loss of consciousness of unspecified
duration, initial encounter
Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial
encounter
Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes
or less, initial encounter
Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes
to 59 minutes, initial encounter
Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5
hours 59 minutes, initial encounter
Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to
24 hours, initial encounter
Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified
duration, initial encounter
Traumatic hemorrhage of right cerebrum without loss of consciousness, initial encounter
Traumatic hemorrhage of right cerebrum with loss of consciousness of 30 minutes or less,
initial encounter
Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59
minutes, initial encounter
Traumatic hemorrhage of right cerebrum with loss of consciousness of 1 hours to 5 hours
59 minutes, initial encounter
Traumatic hemorrhage of right cerebrum with loss of consciousness of 6 hours to 24 hours,
initial encounter
Traumatic hemorrhage of right cerebrum with loss of consciousness of unspecified duration,
initial encounter
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
S06.350A
S06.351A
S06.352A
S06.353A
S06.354A
S06.359A
S06.360A
S06.361A
S06.362A
S06.363A
S06.364A
S06.369A
S06.370A
S06.371A
S06.372A
S06.373A
S06.374A
S06.379A
S06.380A
S06.381A
S06.382A
S06.383A
S06.384A
S06.389A
S06.4X0A
S06.4X1A
S06.4X2A
S06.4X3A
S06.4X4A
S06.4X9A
S06.5X0A
S06.5X1A
S06.5X2A
Traumatic hemorrhage of left cerebrum without loss of consciousness, initial encounter
Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less,
initial encounter
Traumatic hemorrhage of left cerebrum with loss of consciousness of 31 minutes to 59
minutes, initial encounter
Traumatic hemorrhage of left cerebrum with loss of consciousness of 1 hours to 5 hours 59
minutes, initial encounter
Traumatic hemorrhage of left cerebrum with loss of consciousness of 6 hours to 24 hours,
initial encounter
Traumatic hemorrhage of left cerebrum with loss of consciousness of unspecified duration,
initial encounter
Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial
encounter
Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes
or less, initial encounter
Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes
to 59 minutes, initial encounter
Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5
hours 59 minutes, initial encounter
Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24
hours, initial encounter
Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified
duration, initial encounter
Contusion, laceration, and hemorrhage of cerebellum without loss of consciousness, initial
encounter
Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 30
minutes or less, initial encounter
Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 31
minutes to 59 minutes, initial encounter
Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 1 hour to
5 hours 59 minutes, initial encounter
Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of 6 hours
to 24 hours, initial encounter
Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness of
unspecified duration, initial encounter
Contusion, laceration, and hemorrhage of brainstem without loss of consciousness, initial
encounter
Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 30
minutes or less, initial encounter
Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 31
minutes to 59 minutes, initial encounter
Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 1 hour to
5 hours 59 minutes, initial encounter
Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of 6 hours to
24 hours, initial encounter
Contusion, laceration, and hemorrhage of brainstem with loss of consciousness of
unspecified duration, initial encounter
Epidural hemorrhage without loss of consciousness, initial encounter
Epidural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial
encounter
Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial
encounter
Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter
Epidural hemorrhage with loss of consciousness of unspecified duration, initial encounter
Traumatic subdural hemorrhage without loss of consciousness, initial encounter
Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial
encounter
Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes,
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
S06.5X3A
S06.5X4A
S06.5X9A
S06.6X0A
S06.6X1A
S06.6X2A
S06.6X3A
S06.6X4A
S06.6X9A
S06.810A
S06.811A
S06.812A
S06.813A
S06.814A
S06.819A
S06.820A
S06.821A
S06.822A
S06.823A
S06.824A
S06.829A
S06.890A
S06.891A
S06.892A
S06.893A
S06.894A
S06.899A
S06.9X0A
S06.9X1A
S06.9X2A
S06.9X3A
initial encounter
Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes,
initial encounter
Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial
encounter
Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial
encounter
Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter
Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial
encounter
Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59
minutes, initial encounter
Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59
minutes, initial encounter
Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours,
initial encounter
Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration,
initial encounter
Injury of right internal carotid artery, intracranial portion, not elsewhere classified without
loss of consciousness, initial encounter
Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss
of consciousness of 30 minutes or less, initial encounter
Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss
of consciousness of 31 minutes to 59 minutes, initial encounter
Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss
of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss
of consciousness of 6 hours to 24 hours, initial encounter
Injury of right internal carotid artery, intracranial portion, not elsewhere classified with loss
of consciousness of unspecified duration, initial encounter
Injury of left internal carotid artery, intracranial portion, not elsewhere classified without
loss of consciousness, initial encounter
Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of
consciousness of 30 minutes or less, initial encounter
Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of
consciousness of 31 minutes to 59 minutes, initial encounter
Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of
consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of
consciousness of 6 hours to 24 hours, initial encounter
Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of
consciousness of unspecified duration, initial encounter
Other specified intracranial injury without loss of consciousness, initial encounter
Other specified intracranial injury with loss of consciousness of 30 minutes or less, initial
encounter
Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes,
initial encounter
Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59
minutes, initial encounter
Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial
encounter
Other specified intracranial injury with loss of consciousness of unspecified duration, initial
encounter
Unspecified intracranial injury without loss of consciousness, initial encounter
Unspecified intracranial injury with loss of consciousness of 30 minutes or less, initial
encounter
Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes,
initial encounter
Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes,
initial encounter
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
S06.9X4A
S06.9X9A
S09.10XA
S09.11XA
S09.19XA
S09.8XXA
S09.90XA
S09.92XA
S09.93XA
S10.0XXA
S10.83XA
S10.93XA
Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial
encounter
Unspecified intracranial injury with loss of consciousness of unspecified duration, initial
encounter
Unspecified injury of muscle and tendon of head, initial encounter
Strain of muscle and tendon of head, initial encounter
Other specified injury of muscle and tendon of head, initial encounter
Other specified injuries of head, initial encounter
Unspecified injury of head, initial encounter
Unspecified injury of nose, initial encounter
Unspecified injury of face, initial encounter
Contusion of throat, initial encounter
Contusion of other specified part of neck, initial encounter
Contusion of unspecified part of neck, initial encounter
AND
GXXXX: Patient presented within 24 hours of a minor blunt head trauma with a GCS score of 15
and had a head CT ordered for trauma*
*To determine whether or not an emergency department physician ordered a head CT, look for
CPT code 70450.
Denominator
Exclusions
Patients with any of the following:
 Ventricular shunt
 Brain tumor
 Multisystem trauma
 Pregnancy
 Currently taking any of the following antiplatelet medications:
o ASA/dipyridamole
o clopidogrel
o prasugrel
o ticlopidine
To report patient having met denominator exclusion criteria, report:
 GXXX2: Patient meets denominator exclusion criteria (ie, ventricular shunt, brain tumor,
multisystem trauma, pregnancy, or currently taking an antiplatelet medication)
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.
American College of Emergency Physicians
Claims Specifications
Numerator
Denominator emergency department visits for patients who have an indication for a head CT
Indications for a head CT in patients presenting to the emergency department for minor blunt
head trauma:
Patients with any of the following:
 Severe headache
 Vomiting
 Age 65 years and older
 Physical signs of basilar skull fracture (signs include haemotympanum, “panda” eyes,
cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
 Focal neurological deficit
 Coagulopathy
 Thrombocytopenia
 Currently taking any of the following anticoagulant medications:
apixaban, argatroban, bivalirudin, dabigatran, dalteparin, desirudin, enoxaparinm,
fondaparinux, heparin, lepirudin, low molecular weight heparin, rivaroxaban, tinzaparin,
warfarin
 Dangerous Mechanism (ie, ejection from a motor vehicle, a pedestrian struck, and a fall
from a height of more than 3 feet or 5 stairs)
OR
Patients with either loss of consciousness OR posttraumatic amnesia AND any one of the
following:
 Headache
 Age 60 years and older, and less than 65 years
 Drug/alcohol intoxication
 Short-term memory deficits
 Evidence of trauma above the clavicles (physical location, any trauma to the head or neck
[ie, laceration, abrasion, bruising, ecchymosis, hematoma, swelling, fracture])
 Posttraumatic seizure
Quality Data Code for a data element in this numerator :
GXXX3: Patient with minor blunt head trauma had an indication for a head CT
Denominator
Exceptions
None
Additional
Quality Data
Codes used
to report
this measure
If the patient’s head injury occurred greater than 24 hours before presentation to the emergency
department, has a GCS score less than 15, or did not have a head CT ordered for minor blunt
head trauma, report GXXX1.
Reporting
Instructions
To be drafted once measure is static.
© 2014 American College of Emergency Physicians. All Rights Reserved.
CPT ® copyright 2004-2013 American Medical Association.