Assess Claim for Cover :: Simple PICBA claim v41.0
Document 1
Linked Process
Receive and Input Manual Claim :: Early Cover
Team
Linked Process
Match Claim to Recovery
all
Linked Process
Decline Claim
Linked Process
Cover Criteria for Abdominal W Hernia Policy
Linked Process
Accept Claim
6.0
Complete outstanding information requirement(s)
7.0
Early Cover Claim
5.0
Request additional information
N
Y
Is there enough information to make a cover
Linked Process
Accept Claim
4.0
Assess claim
3.0
Confirm eligibility status
Team
riggers & Inputs
T
1.0
Determine if another open claim exists in a Recovery
2.0
Determine actions required to support cover decision
Administrator
Administrator
Assistant
Assistant
Assessor
Assessor
Assessor
Assessor
Cover
Lodgement
Cover
Lodgement
Recovery
Recovery Coordinator
Recovery Partner
Cover
Recovery
Recovery Coordinator
Recovery Partner
Cover
UNASSIGNED
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Simple PICBA claim
Uncontrolled Copy Only : Version 41.0 : Last Edited Tuesday, 30 January 2024 10:24 am : Printed Tuesday, 24 June 2025 7:36 am
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Assess Claim for Cover :: Simple PICBA claim v41.0
Summary
Objective
To review claim information and determine what the cover decision should be, where the Cover Decision Service has not been able
to accept the claim.
this process does not apply to the Remote Claims Unit, Te Ara Tika or any specialist teams (Hearing Loss, Dental, Treatment injury
etc.).
Background
Eos sends a Confirm Cover Decision task for someone to make a manual cover decision. This task type will include a Cover Decision
Required information requirement and one or more of the following cover decision information requirements:
• Cover Assessment Required
• Check Eligibility - Overseas
• Check Eligibility - Dates
• Case Alias Check Required
The task may also include information requirements for information only, such as Address Invalid, Client Address Matches Previous
Home Address.
Global
out of scope
Process
Owner
Global
out of scope
Process
Expert
Variation
out of scope
Expert
Procedure
1.0 Determine if another open claim exists in a Recovery Team
Cover Assessor, Lodgement Administrator
a In Eos, check for any open claims.
NOTE How do you check there is an active managed claim?
The yellow indicator on the General Screen shows the client has an active managed claim.
NOTE What if there is an active managed claim?
Go to Match Claim to Recovery Team.
End of Process.
PROCESS Match Claim to Recovery Team
2.0 Determine actions required to support cover decision
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Open the [Confirm Cover Decision] task.
Do a task with information requirements
b Review the outstanding information requirements to identify what aspects of the claim need to be resolved.
NOTE What if you need to contact the client or provider at any stage during this process?
Ensure you resolve as many outstanding requirements in a single contact as possible.
NOTE What if this is a mandatory data request for a DHB.
Use the Provider Spreadsheet.
Do not use this contact list if you are requesting medical notes via a PO. Provider spreadsheet is used purely for man-
datory data requests only.
Provider Spreadsheet
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Simple PICBA claim
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NOTE What if the claim is for a hernia?
ACC covers a sudden abdominal wall rupture caused by an accident. The force of the accident should be such as to
tear through the layers of the abdominal tissues. The hernia protrudes through the rupture but the covered physical
injury in these cases is the rupture and not the hernia.
The most common type of hernia is located in the groin region. This is known as an inguinal hernia, and about 80% of
hernias are inguinal. The diagnosis of an inguinal hernia caused by an accident is partially made on the basis of an
early presentation following the event, unless there are extenuating circumstances. An early presentation means a
client sought medical attention and was diagnosed with hernia by a medical practitioner or nurse practitioner within 10
days of the event.
Significant groin pain due to an event is one important indicator when causation of an inguinal hernia is being consi-
dered. The other indicators are:
• the event involved an unusual, sudden, unexpected force, as opposed to a controlled movement - these hernias are
typically associated with handlebar or lap seatbelt injuries, or crushing of the abdomen
• the client ceased activity due to the groin pain caused by the event
• there is no prior history of a non-traumatic inguinal hernia on the same side
• the clinical examination by the medical practitioner or nurse practitioner confirms pain, tenderness, and a lump in the
groin region.
If cover has been requested for an inguinal hernia, call the client and complete the 'ACC6261 Cover Assessment - Ini-
tial Call Summary - Hernia' script (This version contains criteria at the bottom of the document to help you assess
cover) . If you're unable to reach the client on the phone, post the ACC6261 Cover Assessment - Questionnaire to
client - Hernia script to the client and have them complete it that way. (This version does not contain the criteria as the
client does not need to see this).
For all other hernia's please refer to the 'ACC7913 Primary Abdominal Wall Hernias, Including Groin Hernias - A Guide
to ACC Cover' document for further guidance.
ACC6261 Cover Assessment - initial call summary - hernia
ACC6261 Cover Assessment – Questionnaire to client - Hernia
ACC7913 Primary Abdominal Wall Hernias, Including Groin Hernias - A Guide to ACC Cover.pdf
NOTE Has the client been sent an automatic electronic notification advising them that we've received their claim?
In general, when a claim is held and sent for a manual cover decision to be made, the client is automatically sent an
electronic notification advising them that we've received their claim and are considering it. You can check the [Contact]
tab to see whether this notification has been sent.
NOTE What are the scenarios when this automatic electronic notification isn't sent?
Automatic claim notification isn't sent if the:
• Client is managed by the Remote Claims Unit or Te Ara Tika branch
• Claim type is Sensitive or Fatal
• Client is deceased
• Client is under 16 years old
• Client has a Safe Contact on their party record
• [Stop Notification] attribute on the client party record is set to [Yes]
• Claim is for a serious injury (determined by the injury diagnosis code)
• Outstanding Case Alias Check Required information requirement is there
• Client has an invalid mobile number.
If the client's mobile number is invalid, a [Notification] task will be created but cancelled automatically. For all other
scenarios above, no [Notification] task will be created.
NOTE What if you're related to or know the client or any of the other parties associated with the claim?
Then you must not make a cover decision for the claim. Transfer the task back to the department it came from and in-
clude the reason for the transfer.
c Check if the claim has the default provider ID: J99966.
NOTE What if the claim has the default provider ID?
• Check if there's a contact on the claim that states the diagnosis is outside provider competency.
• If there is, then resolve the provider competency issue before you continue with this process. Go to Resolve Provider
Competency process below to do this and start at step 3.0 of this process.
#Workaround: Resolve Provider Competency WORKAROUND process is required because Eos raises the Provider
Competency Issue information requirement before the cover decision service has run. As registration is incomplete at
this stage, a Lodgement Administrator cannot add a purchase order to the claim, which is needed to complete the
process. They must add a default provider to the claim to get it through the cover decision service where registration
becomes complete. We'll need to create a standard Resolve Provider Competency Issue process if changes are made
in Eos to only raise this IR after the cover decision service has run (or if admin staff are given permission to enter the
default provider ID and suppress this IR before the cover decision service has run).
PROCESS Resolve Provider Competency Issue
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Simple PICBA claim
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NOTE What if claim type or claim type tick needs to be added or changed?
If after or during assessment it is determined that the claim type tick needs to be changed or added, you can update
on the general tab under claim type. Click edit and tick the relevant box.
NOTE What if claim if determined to be a Treatment Injury Claim
Add TI (Treatment Injury) tick in EOS General screen and transfer claim to Treatment injury administration queue
NOTE What is claim is an Early cover Application via Early Cover Inbox
Go to step 7.0
NOTE What if claim is a Maternal Birth Injury PICBA claim?
If this is a Maternal Bith Injury claim, transfer it to MBI queue.
3.0 Confirm eligibility status
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Check if one or both of the following information requirements are outstanding:
• Check eligibility - dates
• Check eligibility - overseas
NOTE What if one or both of these information requirements are outstanding?
They must be completed before you continue with this process. Go to the Verify Claim Information process below to
do this.
PROCESS Verify Claim Information
NOTE What if you've completed the information requirements and determined that the client is not eligible for
cover?
If the client is not eligible for cover, then you must decline the claim. Go to step 6.0 Complete outstanding information
requirements to complete the information requirements and then decline the claim.
4.0 Assess claim
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Review criteria for cover by reading the policies linked below.
Cover criteria for personal injury Policy
Cover for visitors to New Zealand Policy
Cover for injuries suffered outside New Zealand Policy
Criteria for injury occurring outside New Zealand Policy
Eligibility of late claims Policy
Mental Injuries Policy
NOTE What if it's a change or additional diagnosis?
In addition to the cover criteria outlined in the linked policies, you need to consider
• how much time has passed from the date of lodgement and the date of the accident?
If the new injury would generally have a short recovery period yet the request to add the diagnosis is made sometime
after this period, seek clinical advice.
• what are the differences between the original diagnosis and the new diagnosis?
• how likely that the described accident caused new injury?
• how likely that the underlying conditions (if any), gradual process or ageing caused new
injury?
b Consider if you have enough information to assess claim against the cover criteria. Review the traffic light for cover decisions,
Lodgement Administrators to review information in the Registration Reference Book to help determine this and relating docu-
ments below.
Claims Assessment Traffic Light
Complex Regional Pain Syndrome (CRPS)
Requesting clinical records from District Health Boards
Contacts for requesting District Health Board clinical records
Timeframes to determine cover (Policy)
NOTE What information do you need to consider for the change or additional diagnosis request?
• the date of claim lodgement, the date of the accident and the date we received the request to change/add diagnosis
• the original diagnosis and the new diagnosis
• the description of the accident
• the information on daily activities, age and pre-existing health conditions if applicable
• medical evidence; eg clinical notes, specialist reports and correspondence, x-ray, MRI and other scan results if appli-
cable
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Simple PICBA claim
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NOTE What if the claim is for hernia?
For an Inguinal Hernia contact the client and complete the ACC6261 Cover Assessment - Initial Call Summary -
Hernia document. If unable to contact the client or client would like to complete by themselves you can post the
ACC6261 - Cover Assessment - Questionnaire to client - hernia to the customer along with CVR12. (Please note there
is a difference between the two forms).
For other type's of hernia please refer to the 'ACC7913 Primary Abdominal Wall Hernias, Including Groin Hernias - A
Guide to ACC Cover' document for further guidance.
PROCESS Cover Criteria for Abdominal Wall Hernia Policy
ACC6261 Cover Assessment - initial call summary - hernia
ACC6261 Cover Assessment - Questionnaire to client - Hernia
ACC7913 Primary Abdominal Wall Hernias, Including Groin Hernias - A Guide to ACC Cover.pdf
NOTE What if the cover or additional diagnosis request is for Post Concussion Syndrome?
ACC no longer accepts ‘post-concussion syndrome’ as a covered injury.
Use the “claims assessment traffic light” to aide with a cover or additional diagnosis request.
NOTE: ACC is not reviewing existing cover. If a kiritaki (client) has cover for post-concussion syndrome that remains.
The intent of the position statement is not to restrict entitlements. It is to ensure cover is considered correctly.
Post-concussion syndrome ACC position statement
Guidelines for accepting cover for Concussion
c Review all information and determine whether the claim meets the criteria for cover.
NOTE What if the claim does not meet the criteria for cover?
Go to the Decline Claim process.
PROCESS Decline Claim
?
Is there enough information to make a cover decision?
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
YES....
PROCESS Accept Claim
NO....
Continue
5.0 Request additional information
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Determine who can provide the additional information and request them to submit the information.
NOTE What if you need to ask the client or provider for additional information at lodgement?
Go to 'Contact Client or Provider for Information at Lodgement' process.
PROCESS Contact Client or Provider for Information at Lodgement
NOTE What if you require clinical records?
Review the Request medical or clinical records Policy.
Go to 'Request Clinical Records' process. Note that you need to use MD09 PO code for GP and allied health profes-
sionals' notes.
If you require clinical records from DHB, go to point 3.1 in the process 'Request Clinical Records'.
PROCESS Request Clinical Records
Request medical or clinical records Policy
Requesting clinical records from District Health Boards
Contacts for requesting District Health Board clinical records
NOTE What if you require clinical advice?
Go to 'Seek Internal Guidance' process for Tier 1 and Tier 2 advice.
PROCESS Seek Internal Guidance
NOTE What if a client or provider cannot provide the requested information?
Decline claim due to a lack of information. Go to step 5.0 to complete the information requirements and then to 'De-
cline claim' process.
PROCESS Decline Claim
b Determine if the cover decision timeframe needs to be extended.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Simple PICBA claim
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NOTE How much time do you have to make a cover decision?
You have 21 days to make a cover decision on non-complicated claims from the date ACC received a request, and
two months to make a decision on complicated claims from the date ACC received a request.
Refer to the Timeframes to Determine Cover Policy for complicated and non-complicated claim definitions, and more
information.
Timeframes to determine cover Policy
NOTE What if the cover decision timeframe needs to be extended?
Go to 'Extend Cover Decision Timeframe' process.
PROCESS Extend Cover Decision Timeframe
NOTE How to request information from NZ immigration (Customs/PAX)
When requesting information around a clients international movements from NZ immigration - Also referred to as Cus-
toms or PAX movements, When requesting information around a client's international movements from NZ immi-
gration - Please obtain a signed ACC6300 from the client to attach with the request and include the following blurb:
"I am currently considering a request for ACC cover and I need to confirm (x travel dates) for the following person:
(client’s details).
I’ve attached a signed copy of the ACC6300 "Authority to Collect Medical and Other Records" form, in which the client
authorises ACC to collect information to determine what support ACC can provide.
This request is in line with Principle 2(2)(c) and disclosure is in line with Principle 11(1)(c) of the Privacy Act 2020."
6.0 Complete outstanding information requirement(s)
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
a Update the Cover Decision Required information requirement to [Complete] and also update the Cover Assessment Required
information requirement to [Complete] if it's present on the claim. Ensure all Outstanding information required tasks are com-
plete on the claim.
Complete information requirement
b Clear Information required Tab in EOS and associated tasks
c Check if there are any outstanding information requirements for missing information.
NOTE What if there's one or more outstanding address-related information requirements (Address is Invalid, Client
Address Matches Previous Home Address, Client Already Has an Address Starting Today, Client Already has
a Post Address Starting Today)?
These should be completed before continuing with this process.
Go to Update Client Address process before continuing to step c.
PROCESS Update Client Address
NOTE What if there's an outstanding Phone Number Verification information requirement?
This should be completed before continuing with this process.
Go to Update Client Phone Number process before continuing to step c.
PROCESS Update Client Phone Number
NOTE What if there's an outstanding Vendor Status Removed or Facility Status Removed information requirement?
This should be completed before continuing with this process.
Go to the Resolve Provider, Vendor or Facility Status Issue process before continuing to step c.
PROCESS Resolve Provider, Vendor or Facility Status Issue
d Check if there's an outstanding Case Alias Check Required information requirement.
NOTE What if there's an outstanding Case Alias Check Required information requirement?
This must be completed before continuing with this process. Go to the Identify and Link Duplicate Claims:: Case Alias
IR process before continuing to Accept Claim process.
Note: A claim can only be assessed as a potential duplicate once the cover decision has been determined, as the
cover decision must match the original claim for it to be considered a duplicate.
PROCESS Identify and Link Duplicate Claims :: Triggered by information requirement
7.0 Early Cover Claim
Cover Assessor
a Review the Early Cover Service information within the Traumatic Brain Injury Residential Rehabilitation service page in Pro-
mapp (If necessary).
Traumatic Brain Injury Residential Rehabilitation (TBIRR) Service Overview Service Page
https://au.promapp.com/accnz/process/fc562909-fc94-49ae-b98d-0921f978338f
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b Open the Early Cover Inbox and access the Early Cover request including the ACC7422 form.
c Read the email content and any attachment(s). Mark email as In progress in Outlook.
d In Eos, confirm that the claim hasn't yet been registered. Check for ACC45 / NHI / Client name. If the claim is not registered,
forward the email and attachments to the Registration Inbox. Mark the Email as High priority & URGENT EARLY COVER in
the Subject line.
If we have enough information via the early cover documentation to support / provide cover, we can ask that lodgement accept
the claim after registration & stream to Supported recovery / NGCM. If we need more information, ask that the lodgement team
to Hold the claim to Cover Triage Q.
If we need more information - such as ED admin notes, ask that the lodgement team to Hold the claim to Cover Triage Q. De-
pending on the information provided from the DHB, If you are unsure the claim can be accepted for cover – Seek Hot line guid-
ance from MA. Not All early Cover claims will require MA input or further notes.
If required – depending on the severity of the injuries & client status notifications, letters can be suppressed. Please ensure
this is Noted in your claim accept contact on the claim & NGCM team are aware.
Example:
Good Morning / Afternoon
Can you please have the attached registered for client for Early Cover. Injuries can be covered given the Accident details.
Please accept cover & Stream this claim to NGCM for assistance request.
Thanks
Or
Good Morning / Afternoon
Can you please have the attached registered for client for Early Cover. Please hold this claim to Cover Triage as further infor-
mation is required, can you please advise when this has been done.
Thanks
When the claim has been registered & transferred to the Cover Triage queue, pick up the claim, transfer to your name & action
requests for medical pick up the claim & Request medical notes from the DHB as per Assess claim for cover PICBA process.
Ensure Notes are requested Urgently.
Please note if needed – depending on the severity of the injuries & client status notifications, letters can be suppressed.
Please ensure this is Noted in your claim accept contact on the claim & NGCM team are aware.
NOTE What if the diagnosis on the ACC7422 does't include a read code
The claim must have a read code for the diagnosis for the claim to be lodged. The Cover Assessor should search for
an appropriate read code by either asking the provider, or by searching in the readcode finder tool. If an exact match
is not able to be found, the cover assessor should look to add a read code for a lesser/ more general diagnosis (eg if
the diagnosis on the ACC7422 is for a brain bleed in a specific area, but there is no matching read code, the Cover
assessor may request the claim lodged with "head injury" when sending through to lodgement)
e If able to accept claim, Update claim status and Follow Match Claim to Recovery Team.
** NOTE - Early cover claims are to be matched to SUPPORTED or PARTNERED recovery. Not Assissted or Enabled.
ACC7422 Early cover application form
NOTE What is claim is registered and currently managed by recovery teams
If the claim is allocated to a case owner in supported or partnered recovery – File away the Early Cover documents,
email the staff member to advise early cover application has been received & to consider any further assistance or
Injuries and transfer the claim to the case owner in supported or partnered recovery.
NOTE What if the claim has already been registered?
File away the early Cover application form & name documents on EOS i.e. CT Scan / Ambulance Reports
If the claim is held, check all injuries both in EOS & on the early cover documents are able to be covered with the
information provided from the DHB – some may require full medical notes (Urgent) – refer to Assess claim for cover /
PICBA process.
If required – depending on the severity of the injuries & client status notifications, letters can be suppressed. Please
ensure this is Noted in your claim accept contact on the claim & NGCM team are aware
If the claim is in Actioned cases – check all injuries are covered, add any additional injuries to the claim from the infor-
mation we hold. Re-check / Re-run the EMS tool & stream to appropriate NGCM Team – most transfer to supported
recovery.
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Simple PICBA claim
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NOTE What if the claim hasn't been registered and no claim form is attached to the request?
Email the provider back, marked as high priority asking them to provide Relevant Information, ACC45 – as well as CT
Scans / ACC18 / Ambulance information / ED notes etc. Note Some staff who complete the Early Cover forms at the
hospitals are unable to access full notes so medical notes request will need to be actioned (Assess claim for cover –
PICBA – Marked as Urgent)
NOTE What if the ACC45 has previously been used?
If the ACC45 has been previously used (Not for the current client) & dummy claim number is to be allocated – Forward
the email to Hamilton Registration inbox as Lodgement will need to allocate a new number & register the claim. Refer
to Start of Step D.
Client searches
Guide to completing the new ACC early cover referral form FINAL.dotx
PROCESS
Accept Claim
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
PROCESS
Decline Claim
Cover Assessor, Lodgement Administrator, Recovery Assistant, Recovery Coordinator, Recovery Partner
PROCESS
Cover Criteria for Abdominal Wall Hernia Policy
UNASSIGNED
PROCESS
Match Claim to Recovery Team
UNASSIGNED
PROCESS
Receive and Input Manual Claim :: Early Cover
UNASSIGNED
ACC > Claims Management > Manage Claim Registration and Cover Decision > Make Cover Decision > Assess Claim for Cover :: Simple PICBA claim
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Document 2
Post-concussion syndrome
ACC position statement
The vast majority of traumatic brain injuries are mild, and typically cause transient, self-limiting
symptoms (Clark et al, 2022). Approximately 20% of people report persistent symptoms at 3 months
post-concussion (Thornhill et al, 2000). ACC provides rehabilitation for people who have persisting
symptoms caused by concussion regardless of the duration of these symptoms; for a small minority of
people these symptoms can persist for many months.
The scientific and clinical community have increasingly recognised that there are multiple factors that
influence the persistence of symptoms following concussion, including depression, anxiety, medical
comorbidities, psychosocial stressors, and the emergence of other conditions following injury, such as
post-traumatic stress disorder, functional neurological symptom disorder, and somatic symptom
disorder (Clark et al, 2022).
‘Post-concussion syndrome’ (PCS) was previously supported as a diagnosis that accounted for
persisting symptoms following a concussion. However, the clinical research evidence has increasingly
shown PCS to be a non-specific and clinically unhelpful construct. For example, 50% of people with
depression who have not sustained a concussion meet the diagnostic criteria for moderate to severe
post-concussion syndrome (Iverson, 2006). In response to this clinical research evidence, the diagnosis
of PCS has been removed from the latest versions of the Diagnostic and Statistical Manual of Mental
Disorder (DSM-5) and the International Classification of Diseases (ICD-11). The preferred term to
describe ongoing symptoms is now ‘persisting concussion symptoms’, and associated diagnoses now
include ‘mild neurocognitive disorder’ and ‘neurocognitive disorder due to traumatic brain injury’.
These symptoms can present differently across people who have sustained similar concussion injuries,
with multiple potential maintaining factors that require careful assessment of the affected person to
inform appropriately targeted treatment.
ACC considers that post-concussion syndrome is an unhelpful and out-dated clinical construct. Our
view is that there are risks inherent in continuing to diagnose clients with this condition, not least that
disabling symptoms will be misattributed to this condition rather than to potentially reversible
medical, psychological, or psychiatric factors that remain undiagnosed and untreated. Consequently,
ACC no longer accepts ‘post-concussion syndrome’ as a covered injury. Where clients/patients have
persisting symptoms that clinicians consider are caused by concussion, the appropriate covered injury
would be ‘concussion’. Symptoms that persist beyond three months are most appropriately described
as ‘persisting concussion symptoms.’
This position statement has been endorsed by the Neurological Association of New Zealand (NANZ),
the New Zealand Special Interest Group in Neuropsychology (NZSIGN), the Rehabilitation Medicine
Society of Australia and New Zealand (RMSANZ), The Royal Australian & New Zealand College of
Psychiatrists (RANZCP) and The Royal New Zealand College of General Practitioners (RNZCGP).
References:
Clark, C.N., Edwards, M.J., Eng Ong, B., et al (2022). Reframing postconcussional syndrome as an
interface disorder of neurology, psychiatry, and psychology.
Brain,
145, 1906-1915.
Iverson, G.L. (2006). Misdiagnosis of the persistent postconcussion syndrome in patients with
depression.
Archives of Clinical Neuropsychology,
21, 303-310.
Thornhill, S., Teasdale, G.M., Murray, G.D., et al (2000). Disability in young people and adults one year
after head injury: Prospective cohort study.
British Medical Journal,
320, 1631-1635.
This position statement expires 30 September, 2026.
Concussion
Guidelines to consider before accepting Cover
Document 3
Considerations when accepting cover for Concussion
A claim for concussion is received via an ACC45, ACC18 or ACC32.
The following criteria should be met before accepting cover:
• has been submitted within 3 months of the date of injury.
• ‘Concussion’ or ‘mild traumatic brain injury’ has been diagnosed in the medical records by the treating
doctor within 48 hours of the initial accident:
• The medical records contain supportive clinical information as follows:
o There is a plausible mechanism of injury (e.g. significant blow to the head)
o Medical records refer to concussion symptoms being experienced by the client in the hours (not
days) following the accident (at least ONE of):
• reduction or loss of consciousness (LOC),
• loss of memory for events before the injury (‘retrograde amnesia’) or after the injury
(‘anterograde’ or post-traumatic amnesia (PTA))
• confusion/disorientation
• GCS (Glasgow Coma Score) < (less than) 15
AND, there is NO mention of other influences such as alcohol, drugs, medication issues, or acute
psychological or medical il nesses in the medical records.
If the symbol ‘Ø’ is in the medical records, this means ‘No’.
For example, ‘ØLOC/PTA’ = ‘no LOC/PTA’.
NOTE: Post-concussion syndrome is NOT the same thing as Concussion. Cover for ‘post-concussion
syndrome’ should not be approved without seeking internal guidance ((NGCM) Seek Internal Guidance)
first.
Use ‘S60 Concussion’ when accepting cover on the claim.
Document 4
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MUSCULOSKELETAL NEUROLOGY TRAUMA AND SURGICAL PROCEDURES
An overview of concussion/mild
traumatic brain injury management
for primary healthcare professionals
Concussion is a form of mild traumatic brain injury (mTBI) resulting from an external force to the head or body
that transiently alters brain function. These terms are often used interchangeably in the medical literature,
however, concussion more specifically describes a pattern of symptoms and signs that a person may experience
following mTBI. While clinical management has traditionally centred around “watchful waiting” and extended
rest, there is mounting evidence that passive management can compromise recovery, and that a more
deliberate gradual return to activity is best.
KEY PRACTICE POINTS
Recognising concussion in primary care can be challenging
Patients can be reassured that most people who experience
as symptoms and signs are often subtle, non-specific, and
a concussion will fully recover within two to four weeks.
can progress over time
However, recovery is strongly influenced by the timeliness
– Initial loss of consciousness only occurs in one in ten
of clinical review and follow-up, effective education
people with concussion
delivered at an appropriate level of health literacy (and
whether the advice given is culturally appropriate/relevant),
The Brain Injury Screening Tool (BIST) is a standardised
as well as other patient-specific factors, e.g. initial symptom
and validated assessment tool to evaluate patients with
burden, pre-existing mental health conditions, willingness,
suspected concussion; this is specifically tailored for use in
motivation and support to engage in their recovery.
time-limited clinical consultations
Some patients may continue to experience persistent
Initial management of patients with concussion involves
concussion symptoms lasting longer than three months;
physical and mental rest for 24 – 48 hours; in most cases
addressing these symptoms can be challenging and may
patients should then progressively re-engage in normal
involve reconsidering differential diagnoses, reviewing
activities after this rest period, assuming the degree of
medicine use and assessing mental health status, other
engagement does not significantly worsen symptoms –
stressors and social support
excessive rest can prolong recovery.
– International diagnostic classification systems no longer
Patients who have sustained a sports-related concussion
recognise “post-concussion syndrome” as a diagnostic
should be immediately removed from play, and not return
entity, and the Accident Compensation Corporation
until they have been medically cleared after completing a
(ACC) no longer accepts this as a diagnosis for brain
graduated return-to-play protocol
injury or its subsequent symptoms (see main text for
more details on this)
www.bpac.org.nz
April 2022
1
What is concussion?
Younger people have the highest risk of concussion
The population sustaining concussions is unique with respect
Concussion is defined as “
the acute neurophysiological event
to many other medical conditions in that they are typically
related to blunt impact or other mechanical energy applied to the
active and otherwise healthy.4 Groups at increased risk of
head, neck or body […] which results in a transient disturbance of
concussion in New Zealand include:2, 3, 5, 6
neurological function”.1 This term is often used interchangeably
Younger people – Between 2020 and 2021, people aged
with mild traumatic brain injury (mTBI) in the medical literature,
less than 30 years accounted for 63% of ACC concussion
however, it more specifically describes a pattern of symptoms
claims (Figure 1B)
and signs that a person
may experience following mTBI (see:
Males – Who are almost twice as likely to experience a
“Recognising the symptoms and signs of concussion”).1 As such,
concussion compared with females
while all concussions are mTBIs, not all mTBIs are concussions.
Māori and Pacific peoples – Māori have a 23% higher
The most commonly reported causes of concussion in New
risk of concussion compared with Europeans. The
Zealand are falls, colliding with an object, being struck by a
incidence of all TBIs for Pacific peoples is 1,242 per
person (or animal) and driving-related accidents (including
100,000 person-years, compared with 842 per 100,000
bike accidents; Figure 1A).2, 3 Although people often associate
person-years for Europeans.
concussions with sporting accidents, this only accounts for 20
– 30% of events overall.2, 3 Approximately one-third of sports-
Recognising the symptoms and signs of
related concussions involve people playing rugby union.3
concussion
People with suspected concussion will often seek immediate
A closer look at the demographic trends
review at a hospital emergency department or urgent care
It is estimated that 36,000 people in New Zealand sustain a
clinic. However, others will initially present at their community
traumatic brain injury (TBI) each year, 95% of which are mild in
general practice, sometimes several days to weeks after
severity.2 Many of these people do not seek medical evaluation
injury, particularly if they have mild or delayed symptoms.10
after sustaining a concussion.2 Between 2016 – 2021, an
In some cases, the patient may not have considered that their
average of approximately 21,000 new concussion-related
symptoms could be indicative of a concussion, and therefore
claims per year were lodged with the Accident Compensation
do not immediately report an accident or injury as having
Corporation (ACC)/Te Kaporeihana Āwhina Hunga Whara.3
occurred.
12,000
12,000
10,000
10,000
8,000
8,000
dged
dged
6,000
6,000
4,000
4,000
Total claims lo
Total claims lo
2,000
2,000
0
0
Falls
Collision/
Struck by
Driving-
Other
0–19
20–29 30–39 40–49 50–59 60–69 70–79 80+
knocked over person/animal
related
by object
A. Mechanism of injury
B. Age (years)
Figure 1. New concussion injury claims made to ACC between 1 July 2020 – 30 June 2021 by (A) mechanism of injury and (B) age
group in New Zealand.3
N.B. This time period falls between the first and second nationwide lockdowns associated with the COVID-19 pandemic, and therefore data is not expected
to be significantly affected by corresponding restrictions on people’s activities and daily living. The data and associated trends for this period are similar
to observations for previous years.
2 April 2022
www.bpac.org.nz
Concussions can be chal enging to recognise as the symptoms
Digging deeper to support suspicions
and signs are often subtle, non-specific, and the combination of
features can vary substantially.11 In general, concussion symptoms/
signs can be divided into three main categories: physical,
Ask questions about any recent accidents or injuries
cognitive and behavioural/emotional (Table 1).11 However, no
If a concussion is suspected, a plausible mechanism of injury
features alone, or in combination, are specific for concussion, and
needs to be established. Patients should be asked to describe
many overlap with those seen in other conditions or scenarios, e.g.
any recent accidents or injuries in as much detail as possible,
hypoglycaemia, alcohol or drug intoxication.
including when/where it occurred, details about the event
itself, and what happened directly afterwards up until the time
Loss of consciousness does not usually occur
of the appointment.10 Given that confusion and short-term
While people commonly associate concussion
memory impairment are common features of concussion, this
with loss of consciousness, this occurs in fewer than
information may be derived from a witness account of the
10% of cases.11, 12 However, loss of consciousness
event, via a caregiver or video footage. Concussion should be
means that a concussion is more likely, and prolonged
strongly suspected if there is documented evidence or report
loss of consciousness should raise suspicion of more
of direct trauma to the head/body or exposure to acceleration
serious injury.11
of deceleration forces.11
Table 1. Symptoms and signs associated with concussion.1, 11, 13
Symptoms and signs indicating possible concussion
Physical
Cognitive
Behavioural/emotional
Common
Headache
Confusion/disorientation
Irritability and other transient
Neck pain or tenderness
Brief loss of consciousness
personality changes, e.g.
(mild-moderate)
(< 2 minutes)
disinhibition
Nausea/vomiting
Difficulty concentrating
Emotional lability
Tinnitus
Difficulty remembering things
Psychological adjustment
Taste/smell impairment
Feelings of being “slowed
problems and depressive/
anxious symptoms
Dizziness/vertigo
down” or “in a fog”
Difficulty attending work or
Photosensitivity or sensitivity
Witness reports person was
school
to noise
slow to get up after injury
Fatigue, drowsiness and
Transient diplopia (double
sleep disturbances (including
vision)
insomnia) or sleeping more
Balance or motor
than usual
inco-ordination
Red flags to Worsening of initial symptoms
Prolonged loss of
Increasing restlessness,
consider for Severe or increasing
consciousness (≥ 2 minutes),
agitation, confusion or
emergency referral
headache
or deteriorating conscious
combative behaviours
Severe neck pain
state
Significantly unusual/
Repeated vomiting (as a
Inability to recognise people
inappropriate behaviours or
general guide, more than
or places
personality changes
one vomit in an adult or any
Dysarthria (slurred speech)
vomiting in a child)
Prolonged post-traumatic
Seizures or convulsion
amnesia (> 12 hours)
Ongoing diplopia or other
significant visual disturbances
Weakness, tingling or a
burning sensation in the arms
or legs
Ongoing or severe dizziness/
vertigo
www.bpac.org.nz
April 2022
3
Examples of questions include:10
Do you remember what you were doing when the accident
Pathophysiology associated with
occurred, or were you told this information?
concussion
Did you hit your head, or did your head jolt back and forth?
The pathophysiology associated with concussion is
If so, how hard?
complex and not fully understood.7, 8 However, the
Did anyone say you were lying still or were unresponsive
current international consensus is that concussion
directly after the accident?
occurs as a result of functional disturbances rather than
Were you able to answer questions from people, talk
macrostructural damage, e.g. bruising, bleeding, swelling.8
coherently and think clearly afterwards?
As a result, imaging is not required to diagnose concussion,
Have you previously had a concussion?
and should only be requested if a more severe TBI is
suspected (see: “Diagnose concussion based on clinical
Neurocognitive and physical testing
judgement”).
Sometimes the features of concussion only become apparent
A concussion injury to the brain occurs either as a
when a patient is asked to complete certain tasks that chal enge
result of a direct impact to the head, or via “impulsive”
their neurocognitive or physical abilities, e.g. immediate and
force being indirectly transmitted to the head.8 The
delayed word recall, reciting a sequence of numbers or months
associated biomechanical forces (e.g. rapid acceleration/
in reverse order or balance testing.14 However, no single test
deceleration, rotational forces) disrupt cell membrane
is validated for assessing patients with suspected concussion
and axonal integrity, which triggers an acute cascade
in the absence of a baseline score; instead, a variety of tests
of significant neurometabolic changes.7, 8 During this
usually form part of multifaceted screening assessment to
process the indiscriminate release of glutamate from cells,
identify any additional clinical deficits.14 Examples include
in addition to changes in ionic flux (e.g. potassium efflux,
Vestibular Ocular Motor Screening (VOMS; includes balance,
sodium and calcium influx) triggers “spreading waves” of
vision and movement tests) and the
Standardised Assessment
depolarisation which cause many of the acute symptoms
of Concussion (SAC; includes questions relating to memory
and contributes to inflammation within the brain.7, 8
and cognitive function).
Cerebral blood flow is also reduced following a concussion
Red flags for emergency assessment
event, which reduces the energy available to the brain
for repair.8 Neurometabolic changes may also induce
During the evaluation, identify if there are clinical features
secondary injuries that can progress as the brain attempts
present that may be associated with more serious structural
to compensate and re-establish normal functioning.7, 8
head or cervical spinal injuries or events (e.g. intracranial
The minimum threshold of force required to cause
bleeding), which may require referral for emergency hospital
a concussion is unknown and it is difficult to quantify as
assessment (Table 1).11, 13 A targeted clinical examination
the injury depends on a range of confounding variables,
should be performed in all patients with suspected concussion
e.g. whether the person was able to brace themselves
in primary care, including assessment for:10
before impact or if they have had previous concussions. A
Neurological abnormalities – primarily looking for
study of impacts sustained by high school-aged American
marked motor or sensory deficits associated with cranial
Football players* demonstrated that most concussions
nerves C1 – C8
occurred when the head reached an acceleration value of
For further information on performing
approximately 90 – 100 g-force.9 Notably, the magnitude
neurological assessments, see:
www.
of impact did not consistently predict the severity of
msdmanuals.com/en-nz/professional/
symptoms, supporting the theory that force is not the only
neurologic-disorders/neurologic-examination/
factor associated with this type of injury.9
how-to-assess-the-cranial-nerves
* Force was measured using a wireless accelerometer integrated into
Cervical spine tenderness on palpation and assess
the player’s helmet (The Head Impact Telemetry [HIT] System).
range of motion
Skull fracture – a patient with an obvious scalp wound
will usually have already sought medical attention,
however, consider palpation to detect skull fracture,
particularly depressed fractures
The comparative significance of red flags will likely depend
on the patient’s specific characteristics, e.g. people aged
≥ 65 years or taking an anticoagulant are at elevated risk of
4 April 2022
www.bpac.org.nz
intracranial bleeding.10 Any person who is not lucid or fully
To access BIST and a video walkthrough, visit:
tbin.aut.
conscious should be assumed to have a more severe TBI or
ac.nz/support-and-resources/brain-injury-screening-tool-
cervical spine injury until proven otherwise.13 While vestibular-
bist
dominant symptoms (e.g. dizziness and vertigo) commonly
occur in people with concussion, benign paroxysmal positional
Read the evidence supporting BIST
vertigo (BPPV) should be considered as a differential diagnosis
BIST was initially validated in a retrospective survey of 114
(or co-morbidity) if these symptoms are persistent.10 BPPV can
patients who had experienced a concussion, that demonstrated
be assessed using evaluations such as the
Dix-Hallpike test or
there was a strong correlation between the performance of
supine roll test.10
BIST and other existing tools such as the Sports Concussion
Assessment Tool-Fifth Edition (SCAT-5) and the Rivermead Post-
For further information on vertigo, see: “A delicate balance:
Concussion Symptom Questionnaire (RPQ).16 Feedback from
managing vertigo in general practice” –
bpac.org.nz/bpj/2012/
participants indicated that questions were straightforward to
september/vertigo.aspx
understand and allowed for further modifications to optimise
readability for patients/caregivers.16 A subsequent analysis
Presentation may be delayed in some patients
supported the findings that BIST is a psychometrically reliable
A common misconception regarding concussion is that it
measure of symptom burden following a concussion, and that
always has an acute or early onset, with symptoms emerging
raw scores can be used to inform clinical decisions.17
minutes to hours after the causative event. However,
concussion can sometimes present as an evolving injury with
Why use BIST over other tools such as SCAT-5 and RPQ?
clinical features that change over time, e.g. symptoms may be
Prior to development of BIST, the most widely used clinical
more subtle or absent at first but develop or worsen after 48
assessment tools in primary care included the
SCAT-5 and
– 72 hours.4 Delayed symptom reporting can sometimes occur
the RPQ.16 Both encompass symptom scoring, neurocognitive
if the person experienced other injuries during the incident
and physical assessments, and red flag questions.16 However,
(e.g. fractured shoulder) meaning that they were not engaging
neither tool provides guidance on health care pathway
in daily activities and therefore were unaware of concussion
decision making. SCAT-5 is specifically designed for assessing
symptoms until they returned to activity.
sport-related concussion,* and RPQ is primarily intended for
use in a research setting.16 In addition, the SCAT-5 tool cannot
Tying together the components of clinical
be performed correctly in less than ten minutes,13 and in some
review: The Brain Injury Screening Tool
cases a comprehensive concussion assessment using either
(BIST)
tool may take up to 30 minutes. Therefore, the SCAT-5 and
Given the range of factors that need to be considered, time can
RPQ tools are not ideally suited to the needs of clinicians in
be a major limiting factor within a primary care consultation.
the context of a standard 15-minute appointment.
BIST is a concussion screening tool developed by a group of
* SCAT-5 should still be used on the side-line for concussions sustained
New Zealand clinical experts, for use in people aged eight
while playing sport if professional medical support is available. This tool
years and older when they present for medical care.15 This tool
is designed for use in people aged ≥ 13 years. For children aged < 13
is designed to be completed in six minutes, and encompasses:
years, the
Child SCAT-5 should be used.
Patient details and the injury context, e.g. date, time
Diagnose concussion based on clinical judgement
and mechanism of injury
Ten key prognostic questions relating to clinical
Assessments such as BIST should be applied as support tools;
indicators that may suggest the person is at high risk of
they are not a replacement for clinical judgement, and should
complications and requires hospital evaluation
ideally be used together with other relevant questions and
A 16-item symptom severity checklist, with associated
neurocognitive or physical assessments (as required).15 After
recommendations for referral (e.g. to a specialist
more serious structural or brain injuries have been ruled out, a
concussion service or physiotherapist), or primary care
diagnosis of concussion can be made clinically, supported by
follow-up based on the cumulative score in accordance
evidence of a plausible mechanism of injury and symptoms/
with threshold cut-offs.
signs relating to altered brain functioning.10, 18 Ultimately, a
diagnosis of concussion may not always be clear, regardless
Practice point: Baseline scoring data obtained from
of the examiner’s skill or experience.18 N.B. Laboratory
an initial BIST assessment can be used to facilitate patient
investigation or imaging is not indicated unless differential
monitoring for improvement over time.
diagnoses are suspected.
An evaluation of the overall impact of the injury on
the patient’s quality of life
www.bpac.org.nz
April 2022
5
around rest followed by re-engagement”).10 This is particularly
ACC Concussion Service Referral. The ACC
important for athletes as surveys have shown that, despite
Concussion Service is intended for people with mild
having a baseline knowledge of the risks of playing sport with a
to moderate traumatic brain injuries who are not
concussion, some young adults will still display a willingness to
recovering as expected following an accident and
do so.10 Providing written or printed recommendations is often
have risk factors predictive of a prolonged recovery.
a pragmatic strategy, particularly for patients experiencing
Assuming a patient presents within the first
short-term memory impairment.
few days of their injury to primary care, they should
generally not be referred to ACC Concussion Services
For patient-specific online concussion resources, see:
at the first assessment as symptoms will often resolve
General information (English):
www.acc.co.nz/assets/
after 7 – 14 days. There are risks associated with early
im-injured/acc8319-concussion-education-sheet.pdf
referral and escalation of treatment; in particular, this
General information (Te Reo):
www.acc.co.nz/assets/
course of action may worsen a patient’s perception
acc8319-te-reo-concussion-education-sheet.pdf
of concussion and therefore create mental barriers to
recovery.1 However, referral should be considered if:
Caring for a child with concussion:
www.acc.co.nz/
Symptoms have not improved at follow-up
assets/im-injured/9a24662804/ACC6009-Caring-for-
appointments and are impacting on the person’s
your-child-after-their-head-injury.pdf
ability to do everyday activities e.g. impacting
return to school or work
Management centres around rest followed
More than 14 days has passed since the injury
by re-engagement
when the patient first presents to primary care
and symptoms have not improved
An overview of the specific recommendations and
As of 1st July, 2023, primary care clinicians
considerations relating to concussion management
(and other providers) referring patients to ACC
are detailed in Figure 2.
Concussion Services no longer have to seek
prior approval from ACC. The referral can be sent
Immediate mental and physical rest (i.e. no reading, listening
directly to a concussion provider of choice. For a
to music, watching TV) is essential after a concussion occurs
list of providers in your area, click here.19 ACC and
to minimise brain energy demands and to allow time for
Service providers are responsible for co-ordinating
functional recovery to begin.1 However, it is now accepted
interdisciplinary management, which can be tailored
that excessive rest can impair recovery, and patients should
to a patient’s specific symptom profile, and may
be encouraged to gradually and progressively resume normal
include behavioural, vestibular, vision-oculomotor and
activities following an initial rest period assuming it is done
cognitive rehabilitation interventions.10, 19
in a way that does not cause or worsen symptoms (see Figure
2 and “Expert advice: the “+3 rule” for activity re-engagement”
Having a discussion about concussion
for more details).1, 10, 11 Randomised controlled trial (RCT) data
Once a diagnosis has been made, clinicians should provide
has demonstrated that patients who undertake prolonged and
patients or parents/caregivers with education using language
strict rest for five days following a concussion recover more
and examples that are understandable for their level of health
slowly than those who engage in some form of physical activity
literacy and culturally appropriate, including:10
after 24 – 48 hours.11, 20
An explanation of what concussion is
Progressive engagement in exercise following an initial
How concussion should be managed
rest period is proposed to help recovery through several
Expectations for the recovery timeframe and realistic
mechanisms, such as:21
functional goals
Improving cerebral blood flow – this helps increase
Reassurance and information on the next follow-up step
oxygen and glucose (energy) delivery to the brain for
cellular repair
Encourage patients to take an active role in self-
Promoting the production of brain-derived
management and recovery
neurotrophic factor (BDNF) – this is a protein that
It is essential that patients and their whānau/family have a
functions to support the survival of existing neurons
suitable level of understanding about concussion so they
and encourages the growth and differentiation of new
can appreciate the importance of reporting emerging or
neurons; the expression of BDNF is exercise-dependent,
worsening symptoms, and the value of adhering to the “rest
i.e. increasing the intensity of exercise (according to
to re-engagement” process (see: “Management centres
symptom tolerance) increases BDNF production
6 April 2022
www.bpac.org.nz
Make a clinical diagnosis of concussion
Plausible brain injury mechanism documented
This process can be supported by using the
Symptoms and signs consistent with altered brain functioning
1
Brain Injury Screening Tool (
BIST)
Symptom severity assessed using a scoring criteria
Exclude more serious injury that requires emergency department referral
Deliver recovery advice and reassurance
2
Recommend
Mental and physical rest
Progressive re-engagement
(24 – 48 hours)
Initial stages
Increase activity as tolerated
In a quiet environment
Low-intensity aerobic activities (e.g. walking,
Gradually resume normal
No reading, screen time (e.g. computer,
light jogging)
daily activities
phones, TV) or strenuous activities
Light mental stimulation (e.g. listening to
music or reading
If re-engagement exacerbates symptoms, the activity intensity should be
temporarily reduced to a more tolerable level
Consider
Managing headache or other pain
Other self-care techniques
Managing sleep disturbances:
Prescribe paracetamol if required
Remain hydrated
prioritise behavioural and
for short-term relief
Use an ice/cool pack
environmental changes over
Avoid NSAIDs and aspirin within
intermittently, if required
pharmacological interventions
first 48 hours, as well as opioids
Identify triggers of symptoms;
(see main text for more details)
or other sedatives
avoid these initially
Avoid alcohol or recreational
drugs, if applicable
Guidance for returning to “normal” activities after the 24 – 48 hour rest period
Work
• Consider the following factors:
Gradual work re-entry – e.g. flexible hours or reduced hours; building back up to fulltime work, as tolerated
Job placement – tasks should be matched to the person’s ability and tolerance post-injury; computer-based work may initially
need to be limited
Ensure the workspace is appropriate for recovery – e.g. quiet, supportive and supervised
Driving/transportation requirements to and from work
• Complete ACC45 claim-associated medicated certificate and ACC18/eACC18 form as required
Education
Sport* – immediately remove from play
1. Perform regular daily home-based activities
• Stage 1: players should initially undertake 24 – 48 hours of physical
(i.e. not school-related) if they do not aggravate
and mental rest
symptoms, e.g. reading or watching TV; start
• Stages 2 – 4: during the 2 – 13 days post-injury, players can
with shorter periods, e.g. 5 – 15 minutes and
progressively re-engage in normal daily activities, increase their
progressively increase until activities can be
tolerance for physical and mental activities, before returning to
completed without symptoms
work/study and types of sport-specific training that do not risk head
2. Begin to incorporate school-related activities,
impact.
e.g. homework or other cognitive tasks, while
• Stage 5: after at least 14 days, players can re-engage in full contact-
still remaining at home
based sport specific training if they are asymptomatic and have fully
3. Gradually return to school, guided by
returned to school or work
symptoms; partial days with lighter subjects or
• Stage 6: a minimum of 21 days should have elapsed before players
additional break times may be needed initially
can return to full competition, they should be symptom free during
4. Full return to school activities when tolerated
sports training and they should have received medical clearance
from a qualified medical practitioner (strongly recommended)
Advise patients with a concussion to refrain from driving until they are cleared by a health professional.
If transport assistance is required, contact a local
Brain Injury New Zealand branch to discuss potential support options, or a disability
allowance may be available through ACC.
For further information on head injuries and driving, see:
www.nzta.govt.nz/assets/resources/factsheets/36/docs/36-head-injuries.pdf
Schedule follow-up
• Repeat symptom scoring and consider need for
• Schedule additional follow-up appointments as
(7 – 10 days later)
further assessments to evaluate recovery progress
needed
3
• Check for any emerging red flags
• Consider need for referral to ACC Concussion
• Reinforce appropriate recovery advice
Services
* The progression through these stages and the intensity of re-engagement should be guided by symptoms. If at any point along this pathway there is recurrence of concussion symptoms,
the patient should return to the previous step. People should not return to sport unless they have fully returned to work/education, if applicable. This guidance has been updated since the
initial publication date based on the 2023 ACC concussion guidelines for community sport, available at:
https://www.acc.co.nz/preventing-injury/sport-recreation/concussion-in-sport/
Abbreviations: ACC, Accident Compensation Corporation; CNS, central nervous system; NSAIDs, non-steroidal anti-inflammatory drugs.
Figure 2. The rest to re-engagement strategy for managing patients with concussion in primary care.1, 10, 11, 22, 23
N.B. The full patient assessment and confirmation of diagnosis (Step 1), as well as delivery of recovery advice (Step 2) should occur as early after the
concussion event as possible. This can be challenging to do within the 15-minute period available in a standard primary care appointment, and an
additional consultation may be required.
Managing specific symptoms
Full recovery may take longer than two
weeks
Headache or other pain
Patients can be reassured that almost all people who experience
Concussion symptoms should be expected to resolve without
a concussion fully recover. Data from New Zealand show that
pharmacological intervention.11 If analgesia is required,
approximately half of people recover within two weeks of
prescribe paracetamol for short-term relief but warn patients
the injury, and almost all recover within two months.26 Good
that analgesic overuse can prolong or worsen concussion-
adherence to management advice and effective education
associated headaches.1, 11 Recommend that patients avoid
about concussion enhances recovery time.1
non-steroidal anti-inflammatory drugs (NSAIDs) including
aspirin for at least the first 48 hours (due to bleeding risk) and
Read the evidence
opioids or other sedatives (due to masking central nervous
Until recently, international consensus statements consistently
system effects).1, 11
reported that most people display symptom resolution within
7 – 14 days.11, 22, 26. However, a 2020 prospective analysis of New
Sleep disturbances
Zealand data obtained over two years from 594 people with a
Sleep disturbances are common in patients who have
sports-related concussion (mean age 20.2 ± 8.7 years), found
sustained a concussion, including both hypersomnia (more
that 45% exhibited clinical recovery within two weeks of the
common in initial stages) and insomnia (more common in
injury, 77% within four weeks and 94% within eight weeks.26
later stages).24, 25 Behavioural and environmental changes are
This analysis defined clinical recovery as being when the
recommended first-line, e.g. establishing a regular bedtime,
participant’s SCAT-5 symptom score/severity score was below
avoiding prolonged daytime naps* and not consuming foods
a certain threshold.26 Further investigation is required to assess
or drinks with stimulating effects prior to bedtime.25 If sleep
clinical recovery times in patients with concussion that are not
disturbances persist for several weeks, further consultations
sports-related.
as part of an overal cognitive behavioural therapy approach
is preferred before considering short-term pharmacological
What constitutes “clinical recovery” in primary care?
options.24, 25
Differences in the estimates for recovery time between
*
Expert advice: daytime naps with a duration of < 40 minutes are
clinical studies is likely dependent on the criteria they use and
acceptable in the early stages of recovery.
population assessed.10, 26 In a general practice setting, clinical
recovery from concussion can be defined as the patient having:
For further information on the management of sleep
Minimal symptoms that do not worsen with activity
disturbances and insomnia, see:
Resolution of any abnormal findings on clinical
Non-pharmacological management –
bpac.org.nz/2017/
examination
insomnia-1.aspx
Exercise tolerance, e.g. the patient can exercise at 85%
Pharmacological management –
bpac.org.nz/2017/
of their maximum heart rate* without exacerbating their
insomnia-2.aspx
symptoms
Re-integration into “normal” activities (see: “Guidance for
returning to “normal” activities”)
Expert advice: the “+3 rule” for activity re-engagement
A general approach for guiding activity re-engagement is
For example: if a patient with a baseline headache
to use the “+3 rule”. First ask the patient to give themselves
severity score of four takes a 20-minute walk and their
a baseline symptom severity scoring on a 0 – 10 scale.
perceived score changes to:
After engaging in an activity, the patient should then rate
Seven or more – they should decrease the intensity of
their score again; if the severity of symptoms increases by
their walk the next day or if it was already low intensity,
three or more points compared with their baseline score,
reduce the duration, e.g. to 15 minutes, and then try to
then the intensity of the activity should be temporarily
increase the intensity and/or duration on subsequent
decreased (or duration if already light intensity). If the
days, as tolerated (i.e. provided the symptom severity
activity can be completed without increasing symptom
does not increase by ≥ +3
severity by three or more points, the level of challenge
Six or less – they should increase the intensity of their
can be gradually increased on subsequent days and the
walk the next day and continue to increase the intensity
rule applied again.
of their activity on subsequent days, as tolerated
8 April 2022
www.bpac.org.nz
* This can be estimated by using the formula:
maximum heart rate
= 220 – patient age. For example, a 50-year-old patient would have
an estimated maximum heart rate of 170 beats per minute (bpm); to
Providing culturally appropriate care for
demonstrate exercise tolerance, they would need to be able to exercise
Māori
at approximately 145 bpm without their symptoms worsening.
Strategies relating to concussion management do not
Risk factors associated with prolonged recovery
have to follow a “
one-size-fits-all” approach. Education,
Time to recovery varies between patients depending on a
management and service provision should be culturally
number of risk factors (many of which are pre-injury factors),
responsive and for Māori patients in particular, focus
including:10, 26–29
on the
Whānau Ora model, i.e. addressing individual
Initial symptom burden (strong predictor), i.e. more
needs in the context of their whānau as a whole.2 For
severe acute symptoms correlate with a prolonged
example, consider how the concussion management
recovery.
advice of “rest to re-engagement” will impact on the role
and responsibilities of the patient within their whānau
Previous concussions (strong predictor). Having a
and conversely, the important role that whānau has in
previous concussion increases the risk of sustaining
providing strength and support for their recovery. This
future concussions and may be associated with more
process may be aided by involving a Māori health provider
severe and protracted cognitive deficits if a subsequent
in the care plan, and including relevant cultural practices
one occurs. However, this may be influenced by whether
into a tailored rehabilitation strategy (e.g. Rongoā Māori).2
the patient had not fully recovered from the previous
concussion before experiencing the next.
ACC now funds Rongoā Māori30
Pre-existing mental health conditions (strong
Rongoā Māori is a term encompassing a range of
predictor), e.g. anxiety, depression, Attention deficit
techniques related to the traditional Māori approach to
hyperactivity disorder (ADHD). Pre-existing mood
care and healing. Examples includes mirimiri (traditional
disorders may influence the evaluation of baseline
massage/bodywork), rākau rongoā (native flora herbal
cognitive functioning and make the interpretation of
preparations) and karakia (spirituality and prayer). The
persistent concussion symptoms more difficult, leading
techniques associated with Rongoā Māori place a strong
to a prolonged recovery period.
emphasis on spirituality and whānau connection, and
can help promote restoration of hauora (wellbeing) and
Being female. Females generally present with a greater
recovery through mana motuhake (self-determination).
cognitive deficit and overall symptom severity than
ACC now funds Rongoā Māori in conjunction with
males and longer time for recovery. The underlying
other treatment or rehabilitation approaches, depending
reason for this is unknown.
on a patient’s needs. This is funded under the social
The presence of migraine-like symptoms or a history
rehabilitation category, which is considered separate
of migraine
from treatment, and directed at helping patients return
to independence in activities meaningful to their life/
Younger and older age groups. There is inconsistent
wellbeing. Clinicians wanting to personally deliver Rongoā
evidence to support age-dependent recovery times,
Māori services must register with ACC as a vendor;
a list of
however, some studies how shown that younger people
ACC-registered Rongoā Māori practitioners is available
(e.g. aged < 18 years) or older people (e.g. > 65 years)
on the ACC website.
have a longer concussion recovery duration.
People with alcohol and substance abuse issues
For further information on accessing Rongoā Māori
Predominance of vestibular symptoms, e.g. dizziness
services, see:
www.acc.co.nz/im-injured/what-we-cover/
and balance difficulties. This has been associated with
using-rongoaa-maaori-services/ or discuss this process
poorer long-term outcomes in patients with concussion.
with the ACC Recovery team member managing the
particular claim.
N.B. The mechanism of injury has not been demonstrated to be
predictive of recovery time.10
www.bpac.org.nz
April 2022
9
Follow-up and referral
that can limit vocational engagement; finding the right balance
between beneficial and detrimental mental stimulation can
After diagnosing concussion and establishing a recovery
be challenging.1 Factors to consider when discussing a return
plan (see: Guidance for return to “normal” activities), it is
to work are detailed in Figure 2, but each plan needs to be
recommended that patients should be followed up in primary
individualised depending on the type of work and the support
care within 7 – 10 days to re-evaluate their clinical status
provided by employers.1 Patients who have been referred to
and adjust their rehabilitation protocol if necessary (Figure
ACC concussion services may be eligible for assistance from an
2).1 This process should ideally involve repeating the use of
occupational therapist who can help to identify suitable duties
a symptom scoring tool (e.g. BIST) to quantify any changes
and workplace modifications.
against their baseline level, continued guidance relating
to the management of specific ongoing symptoms and
A module on certifying work capacity after injury is
assessment for the emergence of red flags.1 Further follow-up
available from:
www.goodfellowunit.org/courses/certifying-
consultations can then be scheduled as needed depending on
work-capacity-after-injury
recovery progress.
Medical certificates
Guidance for returning to “normal” activities
General practitioners and nurse practitioners can provide
After sustaining a concussion, a significant concern for many
patients with a medical certificate as part of an ACC45 injury
people is “
when can I return to my normal routine?”. While this
claim to cover the initial 24 – 48 hours rest period when they
question sounds simple, the answer is complex as it depends
are fully unfit for work, up to a maximum of 14 days, as needed.
on what their normal activities involve, the degree of physical,
An ACC18/eACC18 form can also be submitted at the initial
cognitive and emotional impairment caused by the concussion,
consultation to state whether a patient needs to reduce their
and their adherence to recovery advice.1 One of the main
hours or change the type of activities they in engage in upon
priorities when considering a return to work, education, sport
their return to work as part of their rehabilitation for up to 14
or general independence is avoiding any additional brain
days. If the patient is still recovering and continued limitations
injury events; these may be tolerated in people without a
are required beyond this initial timeframe, another ACC18/
previous concussion but even minor accidents can exacerbate
eACC18 form should be completed to confirm they are still only
the already vulnerable neuronal tissue in people with a history
fit for selected work, and ideally include a specified timeframe
of concussion.1 As such, any safe return to “normality” should
for further review or return to normal duties.
involve appropriate restrictions and limitations, which are
progressively withdrawn in accordance with documented
For further information, see:
www.acc.co.nz/for-providers/
symptomatic improvement.1 This journey will be unique for
treatment-recovery/medical-certificates-return-to-work/
each person, and the way with which health professionals
engage in this conversation can have a significant impact on
Return to education
the rehabilitation outcome.1
While early mental overexertion can worsen symptoms in
people with concussion and potentially prolong recovery, a
Return to work
return to studies should not be excessively delayed.32 Most
People with concussion who return to work have an improved
students should be able to return to study within two to four
recovery, social integration, financial stability and overall
days following the strict rest period,10 however, the timeframe
quality of life compared with those who remain out of
will be variable depending on individual factors, and activity
work.31 Therefore, an early return to some form of vocational
restrictions will likely be required initially (detailed in Figure
engagement following the compulsory 24 – 48 hour rest
2).22, 32
period should be a priority for most employed people who
have a concussion, assuming the work environment or duties
Return to sport
does not put them or others at risk of injury.1 Those with jobs
People with a suspected or confirmed sports-related
that exclusively involve driving (e.g. courier drivers, truck
concussion should be immediately removed from play
drivers) are likely be fully unfit for work following a concussion
(regardless of their level of participation) and must complete
while they have any ongoing symptoms that affect their vision,
a 24 – 48 hour physical and mental rest period before
ability to promptly make decisions or react.23
commencing a graduated return to play protocol.11, 33
Individual sporting authorities have different regulations for
There can be various barriers to a successful return to
timeframes and criteria for a graduated return to sport (see
work plan. In particular, fatigue and residual concentration or
below), however, most advise avoidance of contact sports for
memory problems are common concussion-related symptoms
at least two to three weeks, with some recommending a longer
10 April 2022
www.bpac.org.nz
duration, e.g. Rugby. Return to sport should not occur until a
training if they are asymptomatic. Players must
person has been medically cleared as being asymptomatic,
have fully returned to school or work before
and has fully returned to work/education, if applicable.22
returning to contact-based training.
A generalised graduated return to play protocol is detailed in
Stage 6: a minimum of 21 days should have
Figure 2.11, 33
elapsed before players can return to full
competition, they should be symptom free
For sport-specific return to play guidance, refer to
during sports training and they should have
individual sporting bodies, e.g.:
received medical clearance from a qualified
Rugby –
www.nzrugby.co.nz/about-nzr/policies-
medical practitioner (strongly recommended)
regulations-and-rules/safety-and-welfare/concussion/
recover-and-return/
For the full ACC guidelines, see:
www.acc.
co.nz/preventing-injur y/spor t-recreation/
N.B. New Zealand Rugby has a mandatory stand-down
concussion-in-sport/
period of 23 days for people aged 18 years and under,
and 21 days for people aged over 18 years. This includes
a 14-day stand-down period before returning to
Persistent concussion symptoms may occur in a small
moderate-to-high intensity exercise, regardless of the
number of people
patient’s age.
Full recovery can be expected in the majority of patients
who sustain a concussion, however, a small number report
Netball –
netballsmart.co.nz/images/netball-smart/
continuing symptoms that impair their daily functioning and
pdf/NetballSmart_Concussion_Community.pdf
quality of life.34
Soccer/Football –
fit4football.co.nz/wp-content/
The phrase “
persistent concussion symptoms” is
uploads/2021/04/NZF-Concussion-Policy-Updated.pdf
preferred to describe symptoms that are present beyond
Mountain Biking/Cycling NZ –
cyclingnewzealand.
three months of a patient sustaining a concussion, e.g. fatigue,
cb.baa.nz/assets/Website-Files/Homepage/Mountain-
headache, concentration/memory impairment.34 Estimates
Bike/About-MTB/1715-MTBNZ-Concussion-Awareness-
of the prevalence of persistent-concussion symptoms vary
Policy.pdf
substantially in the literature depending on the diagnostic
criteria, population and timing of assessment;34 in some
Update: 2023 ACC concussion guidelines for
cases, patients may have displayed initial clinical recovery
community sport now available
and returned to their “normal” routine, yet report persistent
In late 2023, ACC, in partnership with seven national
concussion symptoms at a later date.
sporting organisations, released new guidelines on the
Historical y, the persistence of symptoms for longer than
recognition and treatment of concussion for people
three months was referred to as “
post-concussion syndrome”.34
participating in community sport. This framework is
However, the use of this term is controversial, particularly
intended to help foster a consistent standard of care,
because:34
irrespective of the sporting discipline.
The symptoms do not always cluster in a predictable
The guidelines include a six-stage graduated return
pattern; persisting individual symptoms are more
to education/work and sport protocol, recommending
commonly reported than combinations, and there are no
that:
universally accepted criteria for a diagnosis
Stage 1: players should initially undertake 24 –
The symptoms are not specific to concussion, and are
48 hours of physical and mental rest
also reported in more severe TBIs, other non-brain
Stages 2 – 4: during the 2 – 13 days post-injury,
injured patients and in otherwise healthy people*
players can progressively re-engage in normal
This term implies a mechanism of persisting neuronal
daily activities, increase their tolerance for
damage, however, the pathophysiology is debated and
physical and mental activities, before returning
not strongly supported in the literature
to work/study and types of sport-specific
Reporting may be influenced by a number of factors,
training that do not risk head impact. The
such as recall bias, misattribution of pre-existing
progression through these stages and the
symptoms, personal beliefs about the injury, malingering
intensity of re-engagement should be guided by
and exaggeration
symptoms.
* It has been reported that if the pre-requisite of having actually
Stage 5: after at least 14 days, players can
experienced a concussion event is excluded, up to half of all people in
re-engage in full contact-based sport specific
general, and 70 – 80% of people with depression or chronic pain, would
meet the definition of “post-concussion syndrome”.34
www.bpac.org.nz
April 2022
11
As a result of these limitations, the Diagnostic and Statistical
Recurrent concussions and the risk of future cognitive
Manual (DSM-5) of the American Psychiatric Association (APA)
or neuropsychological deficits
and International Classification of Diseases 11th Revision
While concussions have traditionally been thought to cause only
(ICD-11) no longer recognise post-concussion syndrome as a
limited and transient behavioural changes, there is increasing
diagnostic entity. Consistent with this stance, ACC no longer
evidence of an association between sustaining multiple
accepts post-concussion syndrome as a diagnosis for brain
concussions and having cognitive or neuropsychological
injury or its subsequent symptoms. If a Read Code is required
deficits later in life.11 When neurodegenerative changes
for patients with persistent concussion symptoms, use either
occur in
a specific progressive pattern, it is termed
chronic
the “concussion” (S60..) or “head injury” codes (S646.). For
traumatic encephalopathy (CTE).35 However, a confirmed link
further information on Read Codes, see:
www.acc.co.nz/
between concussion and CTE has not been established.11
for-providers/lodging-claims/read-codes/.
READ THE EVIDENCE Investigations into the relationship
Addressing persistent concussion symptoms
between multiple concussions and cognitive or
The presence of persistent concussion symptoms is likely
neuropsychological deficits later in life are ongoing. An
dependent on a complex interplay of biological, psychological
analysis of 2,552 retired professional American football
and social factors, and the evidence for effective treatment is
players found that those who had sustained more than three
limited.34
concussions had a five-fold higher prevalence of diagnosed
In patients with symptoms that persist for longer than
mild cognitive impairment and a three-fold higher prevalence
three months:1, 19
of reported significant memory problems compared with
Discuss social support mechanisms and potential
those without a history of concussion.36 While an increased rate
stressors in the environment in which the patient is
of Alzheimer’s disease was not identified, an earlier onset was
recovering, i.e. unstructured household, unsupportive
reported among former players with recurrent concussions.36
workplace, financial stress
In addition, a prospective analysis of > 350,000 United States
Reconsider differential diagnoses outside of the injury-
Military Veterans demonstrated those who had sustained one
context; symptoms may be occurring independently
or more concussion (with or without loss of consciousness)
of the concussion or worsen due to its presence, e.g.
had more than a two-fold higher risk of being diagnosed with
chronic pain, anxiety and depression disorders, sleep
dementia.37 The risk was higher in those who had sustained
disorders and other psychiatric conditions
multiple concussions, and the association was present even
Assess current medicine use, including prescription,
after adjusting for medical and psychiatric co-morbidities.37
over-the-counter medicines or supplements, as well as
alcohol or recreational drug use
There is currently insufficient evidence to define a causal
relationship between multiple concussions and CTE. CTE
Further assessment may be warranted. If this process
can only be diagnosed according to specific pathology criteria
does not uncover a potential cause, an additional and more
detected in autopsied brains; there is no validated clinical
comprehensive neuropsychological and/or neurological
criteria for diagnosing CTE in a living person.35 While there is
assessment(s) is generally indicated for patients with
a correlation between sustaining multiple concussions and
persistent concussion symptoms.19, 22, 34 This differs from the
an increased risk of developing CTE, most studies involve
brief neuropsychological assessment used in evaluation tools,
post-mortem study of professional athletes who regularly
and will likely require an interdisciplinary approach (e.g. with
engaged in high impact activities throughout their life, e.g.
a clinical neuropsychologist) to address the more complex
American Football players.35 Further investigation is warranted
aetiology underpinning the patient’s condition.19, 22
to understand this potential relationship further, e.g. whether
it is a causative association and, if so, to quantify the relative
Neuropsychological assessments through ACC: For
contribution of concussion in the context of other modifiable
patients who have been referred to ACC concussion services,
risk factors.
neuropsychological screening is included as part of the
management pathway.19 When conducted, a brief summary
For further information on concussion:
(including recommendations) must be shared with the
Ontario Neurotrauma Foundation adult concussion/
interdisciplinary team and ACC.19
mild traumatic brain injury guidelines. Available
To read the ACC position statement on post-concussion
braininjuryguidelines.org/concussion/
syndrome/persistent concussion symptoms, see:
www.acc.
PedsConcussion living guidelines for paediatric
co.nz/assets/Uploads/Post-concussion-syndrome-ACC-
concussion care. Available at:
pedsconcussion.com
position-statement.pdf
12 April 2022
www.bpac.org.nz
19. Accident Compensation Corporation (ACC). Concussion Service. Operational
Acknowledgement: Thank you to
Dr Stephen Kara,
Guidelines. Version 3. 2020. Available from: https://www.acc.co.nz/assets/
Sport and Exercise Medical Registrar, Axis Sports Medicine,
contracts/concussion-og.pdf (Accessed Mar, 2022).
Auckland, for expert review of this article.
20. Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute
concussion: a randomized controlled trial. PEDIATRICS 2015;135:213–23.
This article was supported by ACC Injury Prevention and Health
doi:10.1542/peds.2014-0966
Partnerships teams.
21. Leddy JJ, Haider MN, Ellis M, et al. Exercise is medicine for concussion. Current
Sports Medicine Reports 2018;17:262–70. doi:10.1249/JSR.0000000000000505
N.B. Expert reviewers do not write the articles and are not responsible for
22. McCrory P, Meeuwisse WH, Dvořák J, et al. 5th International Conference on
the final content. bpacnz retains editorial oversight of all content.
Concussion in Sport (Berlin). Br J Sports Med 2017;51:837–837. doi:10.1136/
bjsports-2017-097878
23. New Zealand Transport Agency (NZTA). Head injuries and driving. 2021.
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CON.0000458974.78766.58
www.bpac.org.nz
April 2022
13
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Concussion Services Service Page
Document 6
v40.0
Summary
Objective
The Concussion Service is a clinical assessment and rehabilitation service for clients with a mild to moderate traumatic brain injury
(TBI). The service is delivered by an interdisciplinary team of professionals specialised in the diagnosis and rehabilitation of TBI. The
service aims to prevent long-term consequences, such as persisting concussion symptoms, by identifying clients at risk and deli-
vering effective assessments, education, triage and rehabilitation.
Owner
out of scope
Expert
out of scope
Procedure
1.0 Who is this service for?
a Clients who have been diagnosed with a mild to moderate traumatic brain injury, or are suspected of having a brain injury that
needs investigation. The Concussion Service deals with:
• mild to moderate traumatic brain injury (TBI)
• persisting concussion symptoms (PCS).
2.0 Key features
a The purpose of the Concussion Service is to:
• Confirm a diagnosis of concussion or rule out diagnosis of concussion
• Support the Client’s recovery and prompt return to every-day life including work or school
• Reduce the incidence of further brain injury, and long term consequences, such as persisting concussion symptoms by pro-
viding clients with education and effective interventions
The Concussion Service is delivered by an interdisciplinary team (IDT). The core IDT is made up of a:
• Medical Specialist
• Neuropsychologist
• Occupational Therapist
• Physiotherapist
b The IDT may also include a:
• Nurse
• GP
• Speech Language Therapist
• Psychologist
• Social Worker
• Optometrist
c The IDT is co-ordinated by a key worker to ensure that the service is flexible to meet the individual needs of the client.
• The maximum timeframe for treatment within the Concussion Service is 6 months. Ideally clients should be complete treat-
ment and rehabilitation within 16 weeks of referral.
• Clients who have more complex needs should be referred to other services such as: the clinical services contract, neuropsy-
chology contract, Training for Independence (TBI) or other appropriate services.
• Providers should only recommend that a client stay in the Concussion Service if they feel they can achieve an outcome within
the maximum funding limit. If during the assessment phase the providers feel that the clients needs are too complex to be able
to achieve an outcome within this service they should be discharging client out of the Concussion Service at that time and no
further treatment and rehabilitation should be undertaken or invoiced for under the Concussion Service.
• Where a recommendation has been made for a client to exit the concussion service and be referred for a Training for
Independence program, no further treatment should be invoiced for under the Concussion contract. The only exception to this
is if the client still requires a Neuropsychological Screen. In this instance, the Concussion supplier can keep the client’s file
open until the screen has been completed then invoice for the Neuropsychological Screen (TBI23) accordingly.
d Services are delivered up to a maximum spend of $3914.49 (GST exclusive).
e Clients who require more services than are available under the Concussion Service are referred to other services as recom-
mended by the Supplier on the ACC884.
ACC > Claims Management > Manage Claims > Service Pages > Specialist Care and Rehabilitation > Specialist Rehabilitation and Disability Services > Concussion Service >
Concussion Services Service Page
Uncontrolled Copy Only : Version 40.0 : Last Edited Monday, 8 July 2024 1:59 pm : Printed Monday, 23 June 2025 1:29 pm
Page 1 of 7
3.0 Eligibility for Concussion Services
a To be referred to the Concussion Service, the Client must meet all the following criteria:
• Have sustained a TBI (or suspected TBI) within the previous 12 months
• Have an accepted ACC claim, and
• Be diagnosed with or be suspected of having a mild TBI, moderate TBI or persisting concussion symptoms
AND Have at least one of the following on-going signs and symptoms:
• Mood changes
• Memory problems
• Fatigue
• Difficulty concentrating
• Loss of balance
• Headaches
• Visual disturbances
• Nausea
• Muscular aches
• Dizziness
AND have at least one of the additional risk factors such as:
• The inability to work or attend school for more than one week
• Second or subsequent MTBI within 6 months
• Post traumatic amnesia lasting more than 12 hours
• A requirement to operate machinery or drive at work
• A pre-existing psychiatric disorder or substance abuse problem
• A high functioning job such as engineer, medical practitioner or lawyer
• Currently attending secondary or tertiary education
b A client is ‘likely’ to have received a TBI if the mechanism of injury indicates that the head and brain has been moving and then
stopped rapidly, eg as a result of a motor vehicle crash, sports injury or fall from a bike and hitting the ground hard
c If the accident occurred more than 12 months ago, the concussion service should be declined, and other services should be
considered.
4.0 Referrals into the Concussion Service
a The referrer must only refer Clients who meet the eligibility criteria. The Supplier should decline any referral that does not meet
these criteria.
b Referrals can come from the following:
• Te Whatu Ora (Health NZ) hospitals – via a Medical Practitioner or an Allied Health professional acting on behalf of a Medical
Professional
• General Practitioner (GP) or Accident and Medical (A & M)
• ACC – via a Recovery Team Member
• Note: No prior approval is required for Concussion Services apart from the service codes paid 'at cost' (TBI25).
c The referral should be completed using the ACC883 Concussion Service Referral form:
• GP’s and UCCs can send the ACC883 to either ACC or directly to the Concussion Supplier.
Te Whatu Ora (Health NZ) District Hospitals can continue to use the ACC883 but it is preferred that they use the ACC7988.
• If sent to ACC – the Recovery Team Member will approve the service if appropriate and forward the referral document to a
Concussion Supplier.
Te Whatu Ora (Health NZ) District Hospitals can send the ACC7988 directly to the Concussion Supplier. ACC will be cc’d in to
this referral for our records.
If a provider is unable to accept a referral, they will notify ACC, and ACC is to select and refer to another provider using the
current process.
• ACC led referrals can be sent straight to the Concussion Supplier. Recovery Team Members will need to generate the
ACC883 in EOS and fill it in with as much claim details as possible. The ACC883 will then need to be included as part of the
relevant document group prior to the referral task being sent to Recovery Admin to process.
ACC883 Concussion service referral
d For continuity of service, clients should be referred to the Supplier named in the referral information unless there is a reason to
refer the client to a different Supplier, such as:
• a clinical reason the client should be referred elsewhere
• to avoid clients having to undertake unnecessary travel
• the client chooses a particular supplier
• there is another reason that ACC makes in the best interests of the client
e Referrals for children and adolescents into the Concussion Services are made on an ACC7412 which is equivalent to the
ACC883 adult referral form. Prior to sending a referral for children and adolescents, we should check that the Supplier has
expertise to provide services to a Child or Adolescent.
ACC > Claims Management > Manage Claims > Service Pages > Specialist Care and Rehabilitation > Specialist Rehabilitation and Disability Services > Concussion Service >
Concussion Services Service Page
Uncontrolled Copy Only : Version 40.0 : Last Edited Monday, 8 July 2024 1:59 pm : Printed Monday, 23 June 2025 1:29 pm
Page 2 of 7
f Referrals cannot be sent from other clinical professionals (such as a physiotherapist in the community). They may, however,
refer a Client to a registered Medical Practitioner for a medical assessment, after which the Client may be referred to the
Concussion service.
g Clients cannot self-refer into this service.
5.0 Assessment and Triage of Client
a The assessment component of this service covers investigation of the presenting symptoms, diagnosis and treatment as fol-
lows:
• education about mild to moderate traumatic brain injury to the client
• identify and assess the client’s risks to recovery
• all clients undergo a case review by a Medical Specialist and Neuropsychologist to assess the need for full assessments (this
is a file review of all relevant clinical notes)
• investigation of the clinical and psycho-social background of the client
• confirmation of the diagnosis where unconfirmed
• assessment of the client’s therapy needs
• development of a rehabilitation plan
• development of the client summary report
• referral to other services if needed
.
b Phone triage: If a Service Provider after a phone call to the client determines the client doesn't need to enter the concussion
service, the supplier can charge the TBI05 code (no prior approval required).
6.0 Updating the client's diagnosis
a When we don’t have a confirmed diagnosis the case owner must ask the provider to confirm the diagnosis during a medical
assessment.
The provider is responsible for ensuring there is a confirmed diagnosis before therapy services are provided.
b For example, the ACC883 asks the referrer: What is the suspected or confirmed injury diagnosis? If the referrer writes their
suspected diagnosis then the Concussion Supplier will undertake an assessment of the client to determine whether the Client
has a diagnosis of Concussion.
c At times, a GP might list an additional diagnosis of Concussion onto a Medical Certificate stating that a client is not fit for work
due to a concussion and there is no diagnosis listed on the ACC45. In addition, a Concussion Supplier might also list an addi-
tional diagnosis of Concussion on a report to ACC where concussion has not previously been listed on the ACC45.
d In these instances, where a subsequent diagnosis of Concussion has been made:
1) Check that that the diagnosis has been made by a Medical Practitioner as only a Medical Specialist or GP can make a diag-
nosis of Concussion. This is because only a Medical Professional (GP etc) can rule out (or confirm) the presence of any other
medical conditions which may be contributing to the Client’s symptoms.
2) Request lodgement notes or clinical notes
3) Seek Clinical Advice
e Follow the process for updating a client's diagnosis
Updating a Client's diagnosis process
https://go.promapp.com/accnz/Process/Minimode/Permalink/C5dzKYRy4qR26S0w7lTtea
f When we don’t have a confirmed diagnosis the case owner must ask the provider to confirm the diagnosis during a medical
assessment.
The provider is responsible for ensuring there is a confirmed diagnosis before therapy services are provided.
g ACC Position Statement - Post-concussion syndrome
ACC Position Statement - Post Concussion Syndrome
7.0 Reimbursement of costs when requesting a copy of client clinical notes
a Where a Provider provides up to 5 years of clinical notes they can be reimbursed $1 per page up to a max of $30 by sending
an invoice to ACC using the code COPY. A purchase order is not required. ACC can provide a purchase order if costs exceed
$30.
8.0 Treatment and Rehabilitation
a Where the Client requires therapy following the assessment stage, the Treatment and Rehabilitation should cover:
• Providing advice on managing concussion symptoms
• Therapy to help the client manage emotional and psychological issues
• Medical treatment for symptoms which may require medication
• Notifying ACC of the outcome.
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9.0 Provision of Concussion Services to Children
a Children and young people can recover from Concussion and many children can be managed with treatment and education
and support to self-manage their symptoms. However, some children who present with multiple orthopaedic injuries (eg from
playing sport) or repeated head injuries should be escalated to a full Neuropsychological assessment – without any delay in
referral process
NOTE Definition of Children
Children are defined here as 0-16 years, or still at school. The provider will also take the client's developmental stage
into account - eg some 16 year olds may be independent and can be treated in the same way as an adult. Other
clients may be developmentally delayed and remain at school longer.
b Where a Clinical Neuropsychological assessment is undertaken, consideration should be given to whether additional time is
needed as five hours may not be adequate when assessing children and young people.
c Where indicated by the Provider, children may require a longer period of time in the concussion service to allow the provider to
monitor and support the child or young person during the school term.
d Before making the referral, always contact the Supplier first to check they have the specialist skills in their team to provide ser-
vices to children.
e You can also search for Concussion Service Providers and whether they provide child and youth services using the link below
Concussion Service Providers
https://www.acc.co.nz/for-providers/treatment-recovery/referring-to-rehabilitation/concussion-service-providers/
10.0 Timeframes
a The service and stages must be completed within the expected timeframes.
Timeframes - Provider.PNG
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Timeframes - Acc.PNG
PROCESS
Concussion Service Assessments Service Page
11.0 Service details
Concussion Service client non-attendance
https://go.promapp.com/accnz/Process/Minimode/Permalink/DDEFsER0Sno9EMtINEdcs7
Concussion Service therapy
https://go.promapp.com/accnz/Process/1e3cd255-a3fb-415b-9f26-cf504fda7afe
Concussion Service assessments
https://go.promapp.com/accnz/Process/17cb7c4c-fd72-404c-8198-db7ca325f534
Concussion service initial purchase order
https://go.promapp.com/accnz/Process/a722a895-ca69-4265-a5e9-d9c25188afea
12.0 Exclusions
a • Transport of the client to and from the clinic or place of service
• Provider travel to or from their residence to their place of business or the clinic
• Services provided under other entitlements such as:
- inpatient services for traumatic brain injury (TBI)
- elective surgical treatment arising out of any assessment
- social rehabilitation assessments
- vocational rehabilitation services, where there is an identified need for long-term support
- long-term clinical psychological therapy
- comprehensive neuropsychological or neuropsychiatric assessment and treatments
- radiological and other clinical investigations, eg: computerised tomography (CT), magnetic resonance imaging (MRI), electro-
encephalogram (EEG), sleep studies.
13.0 Responsibilities
a ACC responsibilities
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ACC responsibilities.PNG
b Provider responsibilities
Provider Responsibilities
c Referrer responsibilities:
1) Only refer clients who need and will benefit from the Concussion Service. The client should have signs and symptoms of
mild to moderate TBI or persisting concussion symptoms (PCS).
2) Complete and submit an ACC883 Concussion service referral form for approval. Please note: a Medical Practitioner or Te
Whatu Ora Hospital may refer a client using other formats eg a referral letter. This is acceptable if the information provided is
similar standard to the information which would be provided on an ACC883.
d Client responsibilities
The client is responsible for:
• attending scheduled appointments or reorganising them when unable to attend
• participating in the rehabilitation process
• discussing any problems that may impact their recovery with their case manager and provider.
ACC885 Concussion service - did not attend
ACC884 Concussion service client summary
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14.0 Measuring outcomes
a We consider the service successful when:
• the client has returned to the usual activities of everyday life and no longer needs any support from ACC for their brain injury
• services are provided in the shortest timeframe and at the lowest cost, while still being clinically appropriate
• clients are satisfied with the services provided.
15.0 Completing the service
a A client has completed the service when:
• they’ve returned to work and/or everyday life and no longer need support from ACC for their brain injury
• they’ve withdrawn from the service
• we’ve withdrawn the service from the client
• the maximum funding limit is reached
• they’ve received all approved services and no further services have been approved
• Six months from the date of referral has passed.
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