2025 ICD-10-CM code Z87.820
(Active) Effective Date: N/A Factors influencing health status and contact with health services - Persons with potential health hazards related to family and personal history and certain conditions influencing health status 21. Factors influencing health status and contact with health services (Z00-Z99) Feed
Personal history of traumatic brain injury.
The medical necessity for using Z87.820 is to accurately document a past medical history of TBI that may be relevant to future medical care.It is not to be used for active conditions or current symptoms related to the TBI.
The provider is responsible for documenting the presence of the past TBI, ensuring it meets the criteria for the Z87.820 code, and is not being used to describe an active condition.
In simple words: This code is used when a person has had a brain injury in the past that was caused by trauma, such as a blow to the head. It is used when the injury has healed and there are no ongoing problems.
This code indicates a past occurrence of traumatic brain injury (TBI) that has healed. It is used to document the history of TBI when no other active condition related to the injury is present.
Example 1: A patient presents for a routine check-up and mentions a history of TBI from a car accident 10 years prior. The patient has no residual symptoms or ongoing treatment for the injury. Z87.820 would be used to document the past TBI., A patient undergoing surgery for an unrelated condition mentions a history of TBI.Z87.820 would be coded to document this past condition, which could be relevant to anesthesia management or post-operative care., A patient presents with headaches.After a thorough evaluation, the provider determines the headaches are not related to a previous TBI the patient sustained five years ago. The headaches are diagnosed as migraines, and the past TBI is coded with Z87.820.
Documentation should include details of the original TBI, such as the date of the injury, the cause, and any acute treatment received. Confirmation that the TBI has healed and no active conditions related to the injury are present should also be documented.
** This code is not a billable diagnosis on its own. It is used to provide a more complete picture of the patient's medical history. A primary diagnosis related to the current reason for the encounter should also be coded.
- Specialties:Any specialty can utilize Z87.820 as it relates to documenting past medical history. Specialties that commonly encounter patients with a history of TBI include neurology, neurosurgery, physical medicine and rehabilitation, and primary care.
- Place of Service:Any