Diagnosis

Concussion Diagnosis

Concussions can be tricky to diagnose. Though you may have a visible cut or bruise on your head, you can’t actually see a concussion. Signs may not appear for days or weeks after the injury. Some symptoms last for just seconds; others may linger.

Concussions are very common. Some estimates say a mild brain trauma is sustained every 21 seconds in the U.S.

Assessment

Upon ruling out more severe injury, acute evaluation continues with assessment of the concussion. First, the clinician should establish the presence of any loss or other alteration of consciousness (LOC). LOC is relatively rare and occurs in less than 10% of concussions.  The identification of LOC can be very tricky, as the patient may lose consciousness very briefly and this event may not be directly observed by others. By definition, LOC represents a state of brief coma in which the eyes are typically closed and the patient is unresponsive to external stimuli. 

Although helpful in identifying more serious concerns (e.g. skull fracture, hematoma, contusion), traditional neurological and radiologic procedures, such as CT, MRI, and EEG, are not useful in identifying the effects of concussion. Such tests are typically unremarkable or normal, even in athletes sustaining a severe concussion. The reason for this issue is that concussion is a metabolic or functional injury,  rather than a structural injury. Thus, structural neuroimaging techniques are insensitive to the effects of concussion.

Testing

Concussion patients may need testing procedures.  However, it should be noted that the need for advanced imaging in concussion cases is not common.

  • Neurologic examination: This exam allows us to take a detailed look at the various functions of your brain, including reflexes, memory and focus, vision and eye movements, balance and equilibrium, and sensations.  It is the most important part of the concussion assessment.
  • Computerized Posturography: This state-of-the-art equipment helps us assess balance and equilibrium and rehabilitate the injured areas of your brain.
  • X-ray: You may need an x-ray of your neck or head. This is done to check for other injuries, such as a fracture or subluxation..
  • CT scan: A computerized x-ray machine is used to take pictures of your brain or skull in more serious injuries.
  • MRI: This scan uses powerful magnets and a computer to take pictures of your head and blood vessels in more serious injuries. 
  • EEG (brain wave test): may be needed rarely if seizures develop secondary to your injury.
  • Blood work: Blood testing can reveal any number of physiologic abnormalities caused by the concussion.

Diagnosis

Following the above assessments, the diagnosis of concussion or Mild Traumatic Brain Injury (MTBI) will be made using the following diagnosis codes:

850.0 (Concussion, with no loss of consciousness)
Positive injury description with evidence of a direct or indirect forcible blow to the head, plus evidence of active symptoms and/or signs of any type and number related to the trauma; no evidence of LOC, skull fracture, internal bleed (i.e., intracranial injury).

850.1 (Concussion, with brief loss of consciousness < 1 hour)
Positive injury description with evidence of a direct or indirect forcible blow to the head, plus evidence of active symptoms and/or signs of any type and number related to the trauma; positive evidence of LOC; no skull fracture, internal bleed.

850.9 (Concussion, unspecified)
Positive injury description with evidence of a direct or indirect forcible blow to the head, plus evidence of active symptoms and/or signs of any type and number related to the trauma; unclear or unknown injury details and unclear evidence of LOC; no skull fracture, internal bleed.