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Clinical Policy Title: Cognitive rehabilitation for traumatic brain injury

Clinical Policy Number: 15.02.02

Effective Date: December 1, 2013

Initial Review Date: July 17, 2013

Most Recent Review Date: July 20, 2016

Next Review Date: July 2017

Related policies:

None.

ABOUT THIS POLICY: Keystone First has developed clinical policies to assist with making coverage determinations. Keystone First’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by Keystone First when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Keystone First’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Keystone First’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Keystone First will update its clinical policies as necessary. Keystone First’s clinical policies are not guarantees of payment.

Coverage policy

Keystone First considers the use of cognitive rehabilitation to be clinically proven and, therefore, medically

necessary when all of the following criteria are met:

There has been a traumatic brain injury.

Meets criteria for admission to a rehabilitation facility or for outpatient rehabilitation treatment.

Responsive to verbal or visual stimuli and demonstrates ability or potential to make progress and

achieve goals (i.e., not comatose or in a vegetative state).

No current substance abuse or acute psychiatric disorders.

Scores at least Level III or evolving to Levels IV – VI on the Rancho Los Amigos Level of Cognitive

Function Scale (pages 3 – 4).

Specific short- and long-term goals and an anticipated discharge/completion date are documented.

In adults ages 21 and over, the injury occurred no more than six months from date of request.

Policy contains:

Cognitive rehabilitation.

Traumatic brain injury (TBI).

Mild TBI (mTBI)/concussion.

Multidisciplinary rehabilitation.

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Limitations:

All other uses of cognitive rehabilitation are not medically necessary. Furthermore, cognitive

rehabilitation in the following settings is not eligible for coverage of the following services, whose

effectiveness and medical necessity has not been established in the peer-reviewed literature:

Transitional living.

Day or community-based programs.

Vocational rehabilitation.

Structured adult education.

Community re-entry programs.

Behavioral training.

Employment counseling.

Work hardening.

Music, recreation or art therapies.

Intelligence testing.

Alternative Covered Services:

None.

Background

Cognitive rehabilitation includes therapies (delivered by speech, occupational or neuropsychological

therapists) that are designed to improve intellectual, perceptual and behavioral skills after damage to

the central nervous system. These therapies intend ultimately to increase levels of self-management

and independence, through the recovery of lost abilities or development of compensatory strategies.

Interventions include retraining in abilities to think, use judgment and make decisions. The focus is on

correcting deficits in memory, concentration and attention, perception, learning, planning and the

sequencing of tasks. Interventions are further classified as restorative/remedial (using a variety of

repetitive approaches) and compensatory/adaptive (adaptive devices and/or modification of the

environment).

Burden of disease — Head injury is the most common cause of death in young adults in the Western

world, accounting for up to two-thirds of in-hospital deaths and for a much larger proportion of lifelong

disability after trauma. Because head injury can affect neurological, cognitive and muscle abilities,

individuals may face physical, cognitive, behavioral and emotional injuries.

Outcomes and potential for successful rehabilitation depends on the primary brain damage and quality

of early management, adequate referral policy, prompt diagnosis and treatment of mass lesions, as well

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as preventing, limiting and treating processes leading to secondary damage. Challenges in providing care

for individuals with TBIs include the variety of presentation and complexity surround the various

cognitive rehabilitation interventions.

Evaluation — Since its introduction in 1974, the Glasgow Coma Scale (GCS) has been widely adopted as

an initial measure of the severity of brain injury. The GCS score summarizes responses in three domains:

eye opening, verbal and motor. GCS is established as a predictor of both immediate and long-term

outcome after traumatic brain injury. TBI can be categorized as severe, moderate or mild, based on the

presenting GCS. A GCS of ≤ 8 is considered representative of severe brain injury (3 – 8 indicating coma);

9 – 3 moderate brain injury and 14 – 15 mild brain injury or concussion. Patients presenting with severe

brain injury have the highest mortality rate, typically reported in the range of 39 percent to 51 percent.

These patients are also at the highest risk for the development of intracranial hypertension and thus are

most likely to benefit from intervention to control intracranial pressure. Therefore, these groups of

patients will most likely benefit from early intervention, to minimize secondary brain injury. The Rancho

Los Amigos Cognitive Scale (below) further refines outcome prediction and monitoring for rehabilitation

settings.

Study types used in preparing this policy — Systematic reviews for cognitive rehabilitation are listed in

Table 1. These reviews pool results from multiple studies to achieve larger sample sizes and greater

precision of effect estimation, than in smaller primary studies. Other policies are listed in Table 2.

Systematic reviews use predetermined transparent methods to minimize bias, and are therefore rated

highest in evidence grading hierarchies. Economic analyses (cost-effectiveness, benefit or utility studies

report both costs and outcomes but not simple cost studies), sometimes known as efficiency studies,

also rank near the top of evidence hierarchies.

Since searches for primary studies included in systematic reviews often cover several decades, a list of

published reviews provides a “snapshot” of the literature, along with gaps in the evidence base. Table 1

lists systematic reviews for cognitive rehabilitation, along with diagnoses addressed in the reviews, years

of literature covered and major conclusions. Table 2 lists professional association guidelines and other

clinical policies.

Ranchos Los Amigos Cognitive Scale — Describes and monitors a patient’s level of functioning and

progress over extended periods:

Level Classification Definition

I No response. Unresponsive to all stimuli.

II Generalized. Inconsistent, non-purposeful reaction to stimuli.

Responds to pain, but may be delayed.

III Localized. Inconsistent reaction directly related to type of stimulus.

Response to some commands.

May respond to discomfort.

IV Confused Disoriented and unaware of present.

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Level Classification Definition

Occasional agitation with frequent bizarre or inappropriate

responses.

Short attention span and impaired information processing.

V Confused, inappropriate, non-

agitated.

Non-purposeful, fragmented or random responses to complex

tasks.

Appears alert and responds to commands.

Performs previous learned tasks, but unable to learn new ones.

VI Confused appropriate. Goal-directed behavior.

Responses to situation appropriate.

Incorrect responses due to memory difficulties.

VII Automatic appropriate. Robot-like correct routine responses.

Oriented to setting.

Poor insight, judgment and problem-solving.

VIII Purposeful appropriate (stand by

assist).

Consistent person, place and time orientation.

Recalls and integrates past with present.

Depressed, irritable, low frustration tolerance, angry and

argumentative.

IX Purposeful appropriate (may request

stand by assist).

Independently shifts among tasks and completes accurately for

at least two consecutive hours.

May be agitated and depressed.

Self-monitors appropriateness.

X Purposeful and appropriate (modified

independence).

Multi-tasks regardless of environment.

May need periodic breaks.

Irritable and intolerant of frustration in case of illness, fatigue or

stress.

Table 1: Other guidelines/coverage

Citation Content, Methods, Recommendations

CMS ( NMP 129;

2013)

Cognitive rehabilitation post TBI:

≤ three hours per day inpatient rehab following TBI and all of the following:

o Patient meets criteria for rehab admission.

o Patient requires intensive interdisciplinary services ≤ three hrs/day, five – seven

days/week of ≤ two different types of therapy (physical, occupational, speech, cognitive

and pulmonary).

o Specific short- and long-term goals and anticipated discharge date are documented.

o Injury occurred ≤ six months from date of request.

o Patient is responsive to verbal or visual stimuli and demonstrates ability or potential to

make progress and achieve goals.

o Absence of substance abuse or acute psychiatric disorders.

o Rancho Los Amigos Level of Cognitive Function Scale Level III and evolving, or Rancho

IV – VI.

Outpatient:

≤ three hrs/day individualized neuro-cognitive rehab for diagnosed impairments, when part of a

multidisciplinary program with ≤ two types of therapy, no contraindications and all of the following:

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Citation Content, Methods, Recommendations

o Documented specific short- and long-term goals, anticipated discharge date.

o Cognitive interventions are structured, systematic, individualized and restorative.

o Injury ≤ six months from date of request.

o Active in-home setting before injury.

o Responsive to verbal or visual stimuli.

o Ability or potential to progress and achieve goals.

o No substance abuse or acute psychiatric disorders.

Service setting exclusions:

Transitional living.

Day or community-based programs.

Non-medical settings (e.g., clubhouses for socialization).

Social skill development programs.

Supported living programs.

Independent living centers.

Service exclusions:

Vocational rehabilitation.

Structured adult education.

Community re-entry programs.

Behavioral training.

Compensatory devices (e.g., memory or date books, electronic paging and computer-assisted

training).

Employment counseling.

Work hardening.

Music, recreation and art therapies.

Intelligence testing.

Table 2: Glasgow Coma Scale (GCS)

Published by the Centers for Disease Control. Centers for Disease Control and Prevention website.

http://www.cdc.gov/masstrauma/resources/gcs.pdf. May 9, 2003. Accessed Jun. 11, 2015.

Glasgow Coma Scale (GCS)

Eye opening response:

• Spontaneous; open with blinking at baseline — four points.

• To verbal stimuli, command and speech — three points.

• To pain only (not applied to face) — two points.

• No response — one point.

Verbal response:

• Oriented — five points.

• Confused conversation, but able to answer questions — four points.

• Inappropriate words — three points.

• Incomprehensible speech — two points.

• No response — one point.

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Motor response:

• Obeys commands for movement — six points.

• Purposeful movement to painful stimulus — five points.

• Withdraws in response to pain — four points.

• Flexion in response to pain (decorticate posturing) — three points.

• Extension response in response to pain (decerebrate posturing) — two points.

• No response — one point.

Categorization: Coma — No eye opening, no ability to follow commands and no word verbalizations (3 –8 points).

Head Injury Classification:

Severe head injury — GCS score of eight or less;

Moderate head injury — GCS score of nine to 12;

Mild head injury — GCS score of 13 — 15.

(Adapted from Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993).

Searches

Keystone First searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s Guideline Clearinghouse and evidence-based

practice centers.

The Centers for Medicare & Medicaid Services (CMS).

We conducted searches on June 8, 2016. Search terms were “traumatic,” “brain injuries,” “cognition”

neuropsychological tests all MESH and “rehabilitation.”

We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample

sizes and greater precision of effect estimation than in smaller primary studies. Systematic

reviews use predetermined transparent methods to minimize bias, effectively treating the

review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not

simple cost studies), reporting both costs and outcomes — sometimes referred to as

efficiency studies — which also rank near the top of evidence hierarchies.

Findings

Cognitive deficits are a common consequence of traumatic brain injury. Although such deficits are

amenable to rehabilitation, methods for individualizing cognitive interventions are still unrefined.

Functional neuroimaging methods such as positron emission tomography and functional magnetic

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resonance imaging are emerging as possible technologies for measuring and monitoring the cerebral

consequences of plasticity associated with brain injury and for evaluating the effectiveness of

rehabilitation interventions. Functional neuroimaging may even enable more customized and efficient

selection, design, or adaptation of individual cognitive rehabilitation programs. We review the current

literature on functional neuroimaging after traumatic brain injury, relating these findings to cognitive

rehabilitation. Overall, functional neuroimaging after traumatic brain injury has shown reliable

differences in brain activity within several regions of frontal cortex, partly but not uniformly consistent

with neuropsychological and structural findings in traumatic brain injury. We also outline a number of

promising research opportunities for applying functional neuroimaging in traumatic brain injury settings,

along with associated challenges.

Policy updates:

Added statement in the findings section. Updated the clinical trials section.

Summary of clinical evidence:

Citation Content methods, recommendations

SIGN (2013) Key points: Brain injury rehabilitation in adults

Randomized controlled trials (RCTs) or systematic reviews, 1990 ‒ 2011.

Memory impairment after TBI — compensatory memory strategies with clear focus on daily functioning: o Mild-moderate impairment; external aids and internal strategies (visual imagery). o Severe impairment; external compensation focused on function.

Attention deficits post TBI — strategies relevant to personal function.

Executive functioning — meta-cognitive strategies focused on personally relevant problems with planning, problem-solving, and goal management.

Comprehensive/holistic programs should involve multidisciplinary team using goal-focused cognitive, emotional, and behavioral therapies.

Brasure (AHRQ; 2012)

Key points: Multidisciplinary post-acute rehab for moderate to severe TBI in adults

Prospective cohort studies and RCTs, 1980-2012.

Productivity outcomes; heterogeneity among studies precluded overall summary.

Community integration outcomes — one RCT with moderate risk of bias and one cohort with unadjusted results — no summary feasible.

Key overall finding — complexity of TBIs and incompletely defined interventions; heterogeneity of populations precluded pooling results.

No clear benefit of one approach over another.

Hayes (annotated bibliography; 2012)

Key points: Cognitive rehabilitation for TBI

2011 ‒ 2012, study types not specified.

Some evidence for efficacy in memory or social skills.

Comprehensive-holistic cognitive rehab may improve community integration vs. standard neuro-rehabilitation.

No studies report safety.

Variation among studies in targeted domains and rehab protocols; for TBI firm conclusions are difficult.

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Marshall (2012) Key points: CPGs for mTBI with persistent symptoms

Systematic review of available guidelines with consensus recommendations; published guidelines in English or French, 1997 -2008.

Persisting cognitive complaints

Screen for: attention and concentration; processing speed; and memory (Rivermead Post-concussion Symptoms Questionnaire; provided in appendix to full-text article).

Assess for co-morbid conditions that may influence cognition (anxiety, depression, post-traumatic stress disorder (PTSD), pain, fatigue, sleep disturbance, acute stress disorder).

Refer to neuropsychologist experienced with TBI.

Spontaneous cognitive improvement can be expected in most cases of mTBI. Cognitive rehabilitation should be initiated when:

o Cognitive impairments persist on formal evaluation. o Compensatory strategies are needed for resumption of functional activities/work or safety

concerns (self and/or others). o Electronic external memory devices (computers, paging devices, organizers) are effective for

improving function post-mTBI.

Cincinnati Children’s Hospital (2011)

Key points: Speech therapist-directed computer assisted cognitive rehabilitation for acquired brain injury, ages 3 ‒ 21 years

TBI; tumors; arteriovenous malformations (AVMs); seizure disorders; meningitis; encephalitis; cerebrovascular accidents( CVAs); hydrocephalus.

Systematic reviews or analytic primary studies, 1995 – 2011.

Recommended for impairments in processing speed; attention; memory/working memory; inhibition; problem solving.

WLDI (2011) Key points: Head (trauma, headaches, not including stress and mental disorders)

1993 – Study types not specified.

Recommendations for physical therapy but cognitive rehab not specifically addressed.

Lane-Brown (Cochrane; 2009)

Key points: Interventions for apathy after TBI

VA/DoD (2009) Key points: Management of concussion/mTBI Does not include cognitive rehab.

Goliscz (2009) Key points: Occupational therapy for adults with TBI Does not specifically include cognitive rehab.

Kumar (Cochrane protocol; 2009)

Key points: Occupational outcomes after TBI

Turner-Stokes (2006)

Key points: Specialist rehabilitation for reducing dependency and costs for adults with complex acquired brain injuries

Before-and-after data from 297 patients admitted to UK rehab service, 1999 – 2005.

Changes in dependency status were associated with substantial savings in direct costs of ongoing care, especially for high-dependency patients.

Chesnut (AHRQ; Key points:

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1999)

Rehabilitation for TBI

Controlled studies, 1976 ‒1997. Key question 3: Cognitive rehabilitation — Mixed results, but best evidence supported prosthetic aids for memory.

o One study indicates cognitive rehabilitation reduces anxiety; improves self-concept and relationships.

o Two studies support use of computer-assisted cognitive rehab in improving immediate recall.

Cicerone (2011) Key points: Clinical Recommendations for Cognitive Rehabilitation after TBI

Included 112 studies 2003 ‒2008

Defines practice standards, guidelines, and options in 6 areas of therapy: o Attention. o Visio-spatial and praxic deficits. o Language and communication deficits. o Memory deficits. o Executive function deficits. o Comprehensive-holistic neuropsychological rehabilitation.

INCOG (2014) Key points: Guidelines for Cognitive Rehabilitation post TBI

Compilation of previous guidelines and literature focused on assessment of moderate to severe TBI.

Cognitive rehabilitation focuses on those younger than 65, medically stable, without psychiatric illness, and awareness of condition.

Individualized care which is tailored to individuals’ goals and condition (both pre and post injury) is an emerging strategy.

Cha (2013) Key points: Computer-based cognitive rehab for stroke.

Chung (Cochrane; 2013)

Key points: Executive dysfunction in stroke or other adult non-progressive acquired brain damage.

Loetscher (Cochrane; 2013)

Key points: Attention deficits following stroke.

Arends (Cochrane; 2012)

Key points: Return to work in adults with adjustment disorders.

Hoffmann (Cochrane; 2010)

Key points: Cognitive impairment in stroke.

Thomas (Cochrane; 2009)

Key Points: Multiple sclerosis.

O’Brien (2008) Key points: Multiple sclerosis.

Glossary

Aneurysm — Section in the wall of a blood vessel weakened, bulging or otherwise at risk of rupture and

bleeding into surrounding tissues.

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Anoxia — Lack of oxygen.

Coma — State of profound unconsciousness caused by disease, injury or poison.

Traumatic brain injury (TBI) — TBI is an alteration in function or other evidence of brain pathology

caused by external force.

References

Professional society guidelines/others:

Bayley MT, Tate R, Douglas JM, et al. INCOG guidelines for cognitive rehabilitation following traumatic

brain injury: methods and overview. J Head Trauma Rehabil. 2014; 29(4): 290 – 306.

Riechers RG, Care of the patient with mild traumatic brain injury. Glenview (IL): American Association of

Neuroscience Nurses, Association of Rehabilitation Nurses; 2011. p. 35.

Colorado Division of Workers' Compensation. Traumatic brain injury medical treatment guidelines.

Denver (CO): Colorado Division of Workers' Compensation; 2012 Nov 26. p.119.

Department of Veterans Affairs, Department of Defense. VA/DoD clinical practice guideline for

management of concussion/mild traumatic brain injury (mTBI). Washington (DC): Department of

Veteran Affairs, Department of Defense; 2009 Apr. p.112.

Golisz K. Occupational therapy practice guidelines for adults with traumatic brain injury. Bethesda (MD):

American Occupational Therapy Association (AOTA); 2009. p.258.

Peer-reviewed references:

Arends I, Bruinvels DJ, Rebergen DS, et al. Interventions to facilitate return to work in adults with

adjustment disorders. Cochrane Database Syst Rev. 2012. Issue 12.

Borg J, Holm L, Cassidy JD, et al. Diagnostic procedures in mild traumatic brain injury. Results of the

WHO Collaborating Centre Task Force on mild traumatic brain injury. J Rehabil Med. 2004a; 43(Suppl):

61 – 75.

Brasure M, Lamberty GJ, Sayer NA, et al. Multidisciplinary postacute rehabilitation for moderate to

severe traumatic brain injury in adults. Comparative effectiveness review number 72. AHRQ Publication

No. 12-EHC101-EF. June 2012.

Bulger EM, Nathens AB, Rivara FP, Moore M, et al. Management of severe head injury: Institutional

variations in care and effect on outcome. Crit Care Med, 2002; 30(8): 1870 – 1876.

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Cha YJ, Kim H. Effects of computer-based cognitive rehabilitation (CBCR) for people with stroke: A

systematic review and meta-analysis. Neurorehabilitation. 2013; 32(2): 359 – 68.

Chung CSY. Pollock A, Campbell T, Durward BR, et al. Cognitive rehabilitation for executive dysfunction

in adults with stroke or other adult non-progressive acquired brain damage. Cochrane Database Syst

Rev. 2013. Issue 4.

Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive rehabilitation: updated review

of the literature from 2003 through 2008. Arch Phys Med Rehabil. 2011; 92(4): 519 – 30.

Dunning J, Stratford-Smith P, Lecky F, et al. for the Emergency Medicine Research Group. A meta-

analysis of clinical correlates that predict significant intracranial injury in adults with minor head trauma.

J Neurotrauma, 2004; 21(7): 877 – 885.

Hayes, Inc. Cognitive rehabilitation for traumatic brain injury (TBI). Medical Technology Directory Pocket

Summary. Hayes, Inc. Lansdale, Pa. June 2011.

Hoffmann T, Bennett S, Koh CL, McKenna KT. Occupational therapy for cognitive impairment in stroke

patients. Cochrane Database Syst Rev. 2010. Issue 9.

Kumar KS, Kamalesh KS, Macadan AS. Cognitive rehabilitation for occupational outcomes after

traumatic brain injury. Cochrane Database Syst Rev. (protocol).2009. Issue 3.

Lamontagne ME, Gagnon C, Allaire AS, Noreau L. Effect of rehabilitation length of stay on outcomes in

individuals with traumatic brain injury or spinal cord injury: a systematic review protocol. Syst Rev. 2013;

2:59.

Lane-Brown A, Tate R. Interventions for apathy after traumatic brain injury. Cochrane Database Syst.

Rev. 2009. Issue 2.

Loetscher T., Lincoln NB. Cognitive rehabilitation for attention deficits following stroke. Cochrane

Database Syst. Rev. 2013. Issue 5.

Marshall S, Bayley M, McCullagh S, Velikonja D, et al. Clinical practice guidelines for mild traumatic brain

injury and persistent symptoms. Can Fam Physician. 2012; 58: 257-67.

Mower WR, Hoffman JR, Herbert M, Wolfson AB, et al. for the NEXUS II Investigators. Developing a

clinical decision instrument to rule out intracranial injuries in patients with minor head trauma:

methodology of the NEXUS II investigation. Ann Emerg Med, 2002; 40(5): 505 – 514.

O’Brien AR, Chiaravalloti N, Groverover Y, DeLuca J, et al. Evidence-based cognitive rehabilitation for

persons with multiple sclerosis: a review of the literature. Arch Phys Med Rehabil. 2008; 89(4): 761 – 9.

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Sommer JB, Norup A, Poulsen I, et al. Cognitive activity limitations one year post-trauma in patients

admitted to sub-acute rehabilitation after severe traumatic brain injury. J Rehabil Med. June 2013;

45(8) 778 – 784.

Thomas PW, Thomas S, Hilier C, Galvin K, Baker R. Psychological interventions for multiple sclerosis.

Cochrane Database Syst. Rev. 2009. Issue 1.

Turner-Stokes L, Paul S, Williams H. Efficiency of specialist rehabilitation in reducing dependency and

costs of continuing care for adults with complex acquired brain injuries. J Neurol Neurosurg Psychiatry.

2006. 77(5): 634 – 9.

Clinical trials:

Searched clinicaltrials.gov on June 13, 2016 using terms “traumatic,” “brain,” “injury,” “cognitive” and

“rehabilitation.” | Open Studies. 47 studies found, two relevant.

VA Boston Healthcare System Recruiting Boston, Massachusetts . Combining Cognitive Treatment With

Noninvasive Brain Stimulation in Blast TBI. https://clinicaltrials.gov// ct2/show/NCT01596569?

Published May 7, 2012. Updated March 2016. Accessed June 13, 2016.

North Florida/South Georgia Veterans Health System, Gainesville, FL. Cognitive Rehabilitation & Brain

Activity of Attention-Control Impairment in TBI. https://clinicaltrials.gov/ct2/show/NCT02589509?

Published October 13, 2015. Updated December 2015. Accessed June 13, 2016.

CMS National Coverage Determinations (NCDs):

No NCDs identified as of the writing of this policy.

However, there are Medicare Benefit Policy Manuals for cognitive rehabilitation post traumatic brain

injury. National medical policy NMP129. Effective 4/2004.

Medicare Benefit Policy Manual, Chapter 12 - Comprehensive Outpatient Rehabilitation Facility

(CORF) Coverage: http://www.cms.gov/manuals/Downloads/bp102c12.pdf. Revised December

2012. Accessed June 13, 2016

Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services Covered Under Part A:

http://www.cms.gov/manuals/Downloads/bp102c01.pdf. Revised June 27, 2014. Accessed

June 13, 2016.

Local Coverage Determinations (LCDs):

No LCDs identified as of the writing of this policy.

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Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and

bill accordingly.

CPT Code

Description Comment

97532 Development of cognitive skills: attention, memory, problem solving each 15 minutes one-on-one patient contact.

ICD-10 Code Description Comment

S06.300A Unspecified focal traumatic brain injury without loss of consciousness, initial encounter

S06.301A

Unspecified focal traumatic brain injury with loss of consciousness of 30 minutes or less, initial encounter

S06.302A

Unspecified focal traumatic brain injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.303A

Unspecified focal traumatic brain injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.304A

Unspecified focal traumatic brain injury with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.305A

Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.306A

Unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.309A

Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, initial encounter

S06.330A

Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial encounter

S06.331A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter

S06.332A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.333A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.334A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.335A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.336A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.337A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter

S06.338A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

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S06.339A

Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter

S06.360A

Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial encounter

S06.361A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial encounter

S06.362A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.363A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 1 hours to 5 hours 59 minutes, initial encounter

S06.364A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.365A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.366A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.367A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter

S06.368A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

S06.369A

Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter

S06.4X0A Epidural hemorrhage without loss of consciousness, initial encounter

S06.4X0A Epidural hemorrhage without loss of consciousness, initial encounter

S06.4X1A

Epidural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter

S06.4X2A

Epidural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.4X3A

Epidural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.4X4A

Epidural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.4X5A

Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.4X6A

Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.4X7A

Epidural hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter

S06.4X8A

Epidural hemorrhage with loss of consciousness of any duration with death due to other causes prior to regaining consciousness, initial encounter

S06.4X9A

Epidural hemorrhage with loss of consciousness of unspecified duration, initial encounter

S06.5X0A

Traumatic subdural hemorrhage without loss of consciousness, initial encounter

S06.5X1A

Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter

S06.5X2A

Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.5X3A

Traumatic subdural hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

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S06.5X4A

Traumatic subdural hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.5X5A

Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.5X6A

Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.5X7A

Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury before regaining consciousness, initial encounter

S06.5X8A

Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause before regaining consciousness, initial encounter

S06.5X9A

Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter

S06.5X9A

Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter

S06.6X0A

Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter

S06.6X1A

Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter

S06.6X2A

Traumatic subarachnoid hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.6X3A

Traumatic subarachnoid hemorrhage with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.6X4A

Traumatic subarachnoid hemorrhage with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.6X5A

Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.6X6A

Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.6X7A

Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter

S06.6X8A

Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

S06.6X9A

Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter

S06.890A

Other specified intracranial injury without loss of consciousness, initial encounter

S06.891A

Other specified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter

S06.892A

Other specified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.893A

Other specified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.894A

Other specified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.895A

Other specified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

16

S06.896A

Other specified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.897A

Other specified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter

S06.898A

Other specified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

S06.899A

Other specified intracranial injury with loss of consciousness of unspecified duration, initial encounter

S06.9X0A Unspecified intracranial injury without loss of consciousness, initial encounter

S06.9X1A

Unspecified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter

S06.9X2A

Unspecified intracranial injury with loss of consciousness of 31 minutes to 59 minutes, initial encounter

S06.9X3A

Unspecified intracranial injury with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter

S06.9X4A

Unspecified intracranial injury with loss of consciousness of 6 hours to 24 hours, initial encounter

S06.9X5A

Unspecified intracranial injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter

S06.9X6A

Unspecified intracranial injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

S06.9X7A

Unspecified intracranial injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter

S06.9X8A

Unspecified intracranial injury with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

S06.9X9A

Unspecified intracranial injury with loss of consciousness of unspecified duration, initial encounter