From the Guidelines
For Medicare patients with acute traumatic brain injury, the best diagnosis to ensure coverage of a head CT scan is "Acute traumatic brain injury" (ICD-10 code S06.9XXA) with appropriate documentation of the mechanism of injury and neurological symptoms. Medicare typically covers head CT scans for patients with acute head trauma who present with symptoms such as loss of consciousness, altered mental status, severe headache, vomiting, seizures, focal neurological deficits, or if they are taking anticoagulant medications, as supported by the American College of Radiology Appropriateness Criteria 1. Documentation should include a thorough neurological examination, Glasgow Coma Scale score, and specific symptoms that necessitate imaging. The guidelines recommend immediate CT scanning for moderate to severe head injuries or for mild injuries with concerning features, such as those indicated in Variant 2 and Variant 3 of the ACR Appropriateness Criteria 1. The urgency of the scan should be clearly indicated in the medical record, as Medicare distinguishes between emergency diagnostic imaging and routine scans, highlighting the importance of accurate and timely documentation 1. This approach ensures appropriate patient care while meeting Medicare's medical necessity requirements for coverage, aligning with the principles outlined in the ACR Appropriateness Criteria for head trauma 1. Key considerations include the patient's clinical presentation, the severity of the injury, and the potential for neurologic deterioration, all of which guide the decision for a head CT scan and are supported by recent evidence-based guidelines 1.
From the Research
Diagnosis for Head CT Coverage
For a Medicare patient with acute traumatic brain injury, the best diagnosis to get a head computed tomography (CT) scan covered includes:
- Acute subdural hematoma 2
- Epidural hematoma 3, 4
- Subarachnoid hemorrhage 3, 5
- Intracerebral contusion 3, 5
- Depressed skull fractures 4
- Brain contusion 5
Key Factors for Coverage
The following factors can influence the coverage of a head CT scan:
- Presence of neurosurgically significant lesions 4
- Clinical stability of the patient 3
- Timing of the CT scan 3, 5
- Presence of posttraumatic lesions 3
CT Scan Timing
The timing of repeated CT scans is crucial in patients with mild traumatic brain injury (MTBI) and an initially positive scan. Studies suggest that: