Certainty of TBI based on signs, symptoms and imaging result: multisite review of ICD-10-CM codes for intracranial injury and skull fracture treated in EDS
| Level of certainty of TBI | Injury event confirmed by reviewer AND | ||
| Group 1*: signs or symptoms | Group 2†: signs or symptoms | TBI result from head imaging‡ | |
| Highest | 1 or more (OR) | 3 or more (OR) | Positive |
| Medium | 0 (AND) | 0–2 (AND) | Suspected TBI |
| Medium | 0 (AND) | 2 (AND) | Negative |
| Lowest | 0 (AND) | 1 (AND) | Negative |
| None | 0 (AND) | 0 (AND) | Negative |
*Group 1: dazed/foggy/confused, memory problems, any loss of consciousness following an injury event.
†Group 2: nausea or vomiting, headache/pressure in head, dizziness/poor balance, change in vision, poor concentration, sensitivity to noise/light, Irritable/change in mood, drowsiness/change in sleep, speech problems, hearing problems, weakness/numbness following an injury event.
‡Almost all of the imaging of the head, when done, was a CT scan. The online supplemental file 1) lists the specific text in the radiology reports that indicated positive for TBI, suspected TBI and negative for TBI.
ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; TBI, traumatic brain injury.