S02.0, S02.1 | Fracture of skull |
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S06 | Intracranial injury |
S07.1 | Crushing injury of skull |
T74.4 | Shaken infant syndrome |
PDX Collection 4454 (continued) | |
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S069X1A | Unspecified intracranial injury with loss of consciousness of 30 minutes or less, initial encounter |
S06368A | Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter |
The 2022 edition of ICD-10-CM S06.0X9A became effective on October 1, 2021.
Use secondary code (s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code. Type 1 Excludes.
For codes less than 6 characters that require a 7th character a placeholder 'X' should be assigned for all characters less than 6. The 7th character must always be the 7th position of a code. E.g. The ICD-10-CM code T67.4 (Heat exhaustion due to salt depletion) requires an Episode of Care identifier.
Cerebral contusion, Latin contusio cerebri, a form of traumatic brain injury, is a bruise of the brain tissue. Like bruises in other tissues, cerebral contusion can be associated with multiple microhemorrhages, small blood vessel leaks into brain tissue. Contusion occurs in 20–30% of severe head injuries.
TBI SCREENING:Code Z13.850 should be used if TBI screening occurs at a visit, whether or not the screening is positive. A TBI diagnosis code should not be entered for a positive screen since a positive TBI screen does not indicate a TBI diagnosis. A TBI diagnosis code can only be entered for the encounter at which the diagnosis is made.
IMPORTANT NOTE: This Fact Sheet denotes use of International Classification of Diseases, Tenth Revision (ICD-10) codes effective October 1, 2015. ALL PREVIOUS VERSIONS OF THIS FACT SHEET ARE RESCINDED.
USE of Z87.820 CODE:Z87.820 Personal history of traumatic brain injury was developed to indicate that previous TBI occurred and may impact current care. The Z87.820 code is not used in conjunction with the late effect codes; rather the Z code is used when no other code is available to reflect a previous TBI. Normally, the Z87.820 code is used to identify a personal history of injury with or without a confirmed diagnosis. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
The pairing of the symptom code and the late effect code is the ONLY WAY that symptoms can be causally and uniquely associated with TBI and is essential to the accurate classification of TBI.
CODING THE INITIAL ENCOUNTER:The ICD-10-CM codes will now provide the specificity of initial, subsequent, and/or sequela to describe the injury; however the seventh character of A will be used to identify the first time the patient is seen for the injury, regardless of when the injury took place. If an injury occurred in the past several months or even years prior but the patient has never sought treatment for the injury previously, the first time the patient is SEEN for the injury is considered the initial treatment.
Focal traumatic nrain injury—requires an additional digit and a seventh character of S
Unspecified intracranial injury (TBI NOS)—requires an additional digit and a seventh character
The 7th character must always be the 7th position of a code. E.g. The ICD-10-CM code T67.4 (Heat exhaustion due to salt depletion) requires an Episode of Care identifier. T67.4XXA Initial Encounter or T67.4XXD Subsequent Encounter. More Info
Concussion, from the Latin concutere ("to shake violently") or concussus ("action of striking together"), is the most common type of traumatic brain injury. The terms mild brain injury, mild traumatic brain injury (MTBI), mild head injury (MHI), minor head trauma, and concussion may be used interchangeably, although the last is often treated as a narrower category. Although the term "concussion" is still used in sports literature as interchangeable with "MHI" or "MTBI", the general clinical medical literature now uses "MTBI" instead. In this article, "concussion" and "MTBI" are used interchangeably. Frequently defined as a head injury with a temporary loss of brain function, concussion causes a variety of physical, cognitive, and emotional symptoms, which may not be recognized if subtle.
S06.2X7 is a "header" nonspecific and non-billable diagnosis code code , consider using a code with a higher level of specificity for a diagnosis of diffuse traumatic brain injury with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness. The code is NOT valid for the year 2021 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.
suffer brain injuries. More than half are bad enough that people must go to the hospital. The worst injuries can lead to permanent brain damage or death. Half of all TBIs are from motor vehicle accidents. Military personnel in combat zones are also at risk.