INJURY COMORBIDITIES

ICD DIAGNOSIS

Definition

ICD-10 Diagnosis Codes assigned by acute hospital(s) on discharge.

Form

[X] Form 1
[ ] Form 2

Source

Abstraction (acute record)

Details

These codes should be assigned by medical records and recorded on the chart at acute discharge. Numbers should be coded just as they appear on the record and not padded with zeros.

This variable should include all ICD-CM codes from any system acute care hospitalization irrespective of relatedness to TBI. If there are multiple acute stays, ICD-CM codes should be taken from all acute stays.

Do NOT include V, W, X or Y codes, as these are “External Causes of Morbidity” codes which should only be coded under the ICD External Cause of Injury Codes variables.

If you suspect errors in ICD-CM coding and can verify correct codes, please use corrected codes.

Sources of Abstraction

ICD Final diagnosis codes abstracted from the medical record should only include Final ICD codes assigned at discharge from the acute record found in either of the following locations:
- Problem List or Final Diagnosis list
- Acute billing/business department
- Trauma Registry
- As a last resort, coding can be completed using description from a final problem list or diagnosis list assigned at discharge from the acute center (see below for additional guidance).

If the list of Final Diagnosis ICD 10 is not available on the main page of the EMR, attempts should be made to obtain this list through access to the ‘Hospital account’ or ‘Patient Account’ section in the EMR by contacting your IT department if the acute facility is part of your EMR or speaking with your acute facility contact that assists with record requests.

ICD 10 Codes found in the EMR should be verified that they are dated with the same date as the acute discharge date to ensure these codes assigned at discharge from the acute center.

If the list of Final Diagnosis ICD 10 codes is not available, obtain from valid coding sources such as a list of final billing codes (some centers have been successful at obtaining this list through the acute Billing department) or Trauma Registry codes for the full acute stay.

Codes should not be taken from the Physician Discharge summary, nor should they be assigned codes from this or any other narrative in the medical record.

Coding ICD-10 codes from a Problem List or Final Diagnosis List

If there is a “Problem List” in the acute medical record that has word-for-word code descriptions without the ICD code associated with the description, a data collector can enter the description in the ICD database and search to identify the appropriate code, using the ICD10 Data website - https://www.icd10data.com (see Link below)

To find an ICD code associated with a diagnosis description, copy the full description into the ICD 10 Data website’s search bar. For example, a search for ‘Post-Traumatic Hydrocephalus’ returns the description ‘Post-traumatic hydrocephalus, unspecified’ with a code of “G91.3”. This is a valid diagnosis and code.

However, a search for “Critical polytrauma” returns a description for “Critical illness myopathy”, along with a variety of additional descriptions that do not match, so this diagnosis would not be included. Similarly, a search for “pulmonary contusion”, fails to yield an exact match, instead providing a list of other more specific options like “Contusion of throat” and “Contusion of [other body parts]”, none of which match, and should also not be included.

Characteristics

Only brain injury-related ICD codes were collected from 1989-10/1/2007.

From 10/1/2007 to 4/1/2015, the first 20 ICD codes were recorded and included codes beyond those that were brain injury-related.

On 4/1/2015, the 20 ICD code limit was removed and coding was expanded to include all ICD’s recorded.

V-codes were included only when using ICD-9-CM.

ICD 9 CM Related: (moved to collecting ICD-10-codes only in 2017)

The ‘99999. Unknown’ code in the database should not be confused with the ICD-9-CM code for ‘99999. Other Unspecified Complication.’

ICD codes in the database have variability due to a number of factors, including but not limited to: center-to-center differences in data sources, ICD-9 to ICD-10 transition, and extension from 20 to unlimited ICD codes in the TBIMS National Database after 4/1/2015

Users should carefully inspect their data and rates of diagnosis for these potential sources of bias that are unrelated to true differences in rates of diagnosis in the sample

Users should consider restricting their sample (e.g., to certain centers with high overall number of ICD codes; certain years; post 4/1/2015 to include all ICD codes

Variables

Form Type

Variable

ID

Question

History

Form 1

Mod1ICDold

3490

Please Enter All Abstracted ICDs

2014-04-01 - Variable Added

Form 1

ICDCount

ICD Count

Codes and Values

ID 3490: No codes found.
ID NA: No codes found.

History

Date

Description

2021-08-06

Added NOTE : If there is a "Problem List" in the acute medical record that has word-for-word code descriptions but not the ICD code associated with the description, a data collector can enter the description in the ICD database and search to identify the appropriate code.

2024-11-05

Added Note: "Do NOT include V, W, X or Y codes, as these are "External Causes of Morbidity" codes which should only be coded under the ICD External Cause of Injury Codes variables." This is not a change in procedure. Just adding clarification to the DD.

2026-10-15

Note Removed: It is recommended by the Data Committee that only ICD codes reported in the medical record should be used.

2026-10-15

Notes Added: Data Dictionary Updates as follows
• ICD Final diagnosis codes abstracted from the medical record should only include Final ICD codes assigned at discharge from the acute record found in either of the following locations:
o Problem List or Final Diagnosis list
o Acute billing/business department
o Trauma Registry
o As a last resort, coding can be completed using description from a final problem list or diagnosis list assigned at discharge from the acute center (see below for additional guidance).
• If the list of Final Diagnosis ICD 10 is not available on the main page of the EMR, attempts should be made to obtain this list through access to the ‘Hospital account’ or ‘Patient Account’ section in the EMR by contacting your IT department if the acute facility is part of your EMR or speaking with your acute facility contact that assists with record requests.
• ICD 10 Codes found in the EMR should be verified that they are dated with the same date as the acute discharge date to ensure these codes assigned at discharge from the acute center.
• If the list of Final Diagnosis ICD 10 codes is not available, obtain from valid coding sources such as a list of final billing codes (some centers have been successful at obtaining this list through the acute Billing department) or Trauma Registry codes for the full acute stay.
• Codes should not be taken from the Physician Discharge summary, nor should they be coded from this or any other narrative in the medical record.


Coding ICD-10 codes from a Problem List or Final Diagnosis List
• If there is a “Problem List” in the acute medical record that has word-for-word code descriptions without the ICD code associated with the description, a data collector can enter the description in the ICD database and search to identify the appropriate code, using the ICD10 Data website - https://www.icd10data.com
• To find an ICD code associated with a diagnosis description, copy the full description into the ICD 10 Data website’s search bar. For example, a search for ‘Post-Traumatic Hydrocephalus’ returns the description ‘Post-traumatic hydrocephalus, unspecified’ with a code of “G91.3”. This is a valid diagnosis and code.
• However, a search for “Critical polytrauma” returns a description for “Critical illness myopathy”, along with a variety of additional descriptions that do not match, so this diagnosis would not be included. Similarly, a search for “pulmonary contusion”, fails to yield an exact match, instead providing a list of other more specific options like “Contusion of throat” and “Contusion of [other body parts]”, none of which match, and should also not be included.

2026-10-15

Added CHARACTERISTICS: Recommendations for Users (This will be added to the “Characteristics of Data” section of the Data Dictionary)
• ICD codes in the database have variability due to a number of factors, including but not limited to: center-to-center differences in data sources, ICD-9 to ICD-10 transition, and extension from 20 to unlimited ICD codes in the TBIMS National Database after 4/1/2015
• Users should carefully inspect their data and rates of diagnosis for these potential sources of bias that are unrelated to true differences in rates of diagnosis in the sample
• Users should consider restricting their sample (e.g., to certain centers with high overall number of ICD codes; certain years; post 4/1/2015 to include all ICD codes

ICD DIAGNOSIS - CALCULATED

Variables

Form Type

Variable

ID

Question

History

Form 1

ICDs

7644

Indicator of ICD Codes Entered

Codes and Values

ID 7644

For Form: [Form 1]
For Variables: [ICDs]

Code

Description

0

No

1

Yes

History

No history found for the Domain.