Complete ICD-10-CM coding and documentation guide for icd-10 coding for brain trauma includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Brain Trauma
Use ICD-10 code S06.0X0A for concussion without loss of consciousness, initial encounter, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Glasgow Coma Scale score 9-12
Use to document the severity of consciousness impairment in TBI cases.
Glasgow Coma Scale score 13-15
Use to document the level of consciousness at the time of assessment.
The ICD-10 code for a concussion without loss of consciousness is S06.0X0A. It is used when a patient presents with a concussion and there is no documented loss of consciousness.
For a traumatic brain injury with a 45-minute loss of consciousness, use ICD-10 code S06.2X1A, which covers diffuse TBI with LOC between 31 and 59 minutes.