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Home/Diagnosis/ICD-10 Coding for Trauma to Head

ICD-10 Coding for Trauma to Head

S06.0X0
S06.2X9D

Complete ICD-10-CM coding and documentation guide for icd-10 coding for trauma to head includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Head Injury
Cranial Trauma
Brain Injury
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Key Information: ICD-10 Coding for Trauma to Head

Essential facts and insights about ICD-10 Coding for Trauma to Head

Use ICD-10 code S06.0X0 for concussion without loss of consciousness, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Concussion without loss of consciousness

Non-Billable
S06.0X0
Non-Billable

Diagnostic Criteria

clinical:
  • • Presence of concussion symptoms without LOC

Applicable To

  • • Mild traumatic brain injury

Important Notes

  • • Ensure LOC is clearly documented to avoid unspecified coding.

Diffuse traumatic brain injury with unspecified duration of loss of consciousness, subsequent encounter

Billable Code
S06.2X9D
Billable

Diagnostic Criteria

clinical:
  • • MRI showing diffuse axonal injury
  • • Documentation of subsequent encounter

Applicable To

  • • Diffuse axonal injury

Important Notes

  • • Ensure the encounter type is correctly documented as subsequent.
Ancillary Codes

Additional codes that may be used with this diagnosis

Z87.820

Personal history of traumatic brain injury

Use for follow-up visits to indicate a history of TBI.

R40.2

Coma scale

Use to document the Glasgow Coma Scale score.

Frequently Asked Questions

What is the ICD-10 code for head trauma?

The ICD-10 code for head trauma varies based on specifics like loss of consciousness and injury type, commonly using codes in the S06.0X-S06.9X range.

How do you code a concussion with loss of consciousness?

For a concussion with loss of consciousness, use S06.0X1 for LOC less than 30 minutes, and S06.0X2 for LOC between 30 minutes and 24 hours.

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