Major or mild NCD due to Alzheimer’s disease commonly co—occurs with major or mild vascular NCD, in which case both diagnoses should be made. Major or mild vascular NCD and depression frequently co-occur.
Due to Traumatic Brain Injury
A. The criteria are met for major or mild neurocognitive disorder.
B. There is evidence of a traumatic brain injury—that is, an impact to the head or other mechanisms of rapid movement or displacement of the brain within the skull, with one or more of the following: 1. Loss of consciousness.
2. Posttraumatic amnesia.
3. Disorientation and confusion.
4. Neurological signs (e.g., neuroimaging demonstrating injury; a new onset of sei- zures; a marked worsening of a preexisting seizure disorder; visual field cuts; an- osmia; hemiparesis).
C. The neurocognitive disorder presents immediately after the occurrence of the trau- matic brain injury or immediately after recovery of consciousness and persists past the acute post-injury period.
Coding note: For major neurocognitive disorder due to traumatic brain injury, with behavioral disturbance: For |CD-9-CM, first code 907.0 late effect of intracranial injury without skull frac- ture, followed by 294.11 major neurocognitive disorder due to traumatic brain injury, with be- havioral disturbance. For |CD-10-CM, first code $06.2X98 diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela; followed by F02.81 major neurocog- nitive disorder due to traumatic brain injury, with behavioral disturbance.
For major neurocognitive disorder due to traumatic brain injury, without behavioral distur- bance: For |CD-9-CM, first code 907.0 late effect of intracranial injury without skull fracture, followed by 294.10 major neurocognitive disorder due to traumatic brain injury, without be- havioral disturbance. For |CD-10-CM, first code $06.2X9S diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela; followed by. F02.80 major neurocog- nitive disorder due to traumatic brain injury, without behavioral disturbance.
For mild neurocognitive disorder due to traumatic brain injury, code 331.83 (631.84).
(Note: Do not use the additional code for traumatic brain injury. Behavioral disturbance cannot be coded but should still be indicated in writing.)
Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury 625
Rate the severity of the neurocognitive disorder (NCD), not the underlying traumatic brain injury (see the section ”Development and Course” for this disorder).
Major or mild NCD due to traumatic brain injury (TBI) is caused by an impact to the head, or other mechanisms of rapid movement or displacement of the brain within the skull, as can happen with blast injuries. Traumatic brain injury is defined as brain trauma with spe- cific characteristics that include at least one of the following: loss of consciousness, post— traumatic amnesia, disorientation and confusion, or, in more severe cases, neurological signs (e.g., positive neuroimaging, a new onset of seizures or a marked worsening of a pre- existing seizure disorder, visual field cuts, anosmia, hemiparesis) (Criterion B). To be at- tributable to TBI, the NCD must present either immediately after the brain injury occurs or immediately after the individual recovers consciousness after the injury and persist past the acute post-injury period (Criterion C).