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Home/Diagnosis/ICD-10 Coding for Traumatic Brain Injury

ICD-10 Coding for Traumatic Brain Injury

S06.0X0A
S06.1X1A

Complete ICD-10-CM coding and documentation guide for icd-10 coding for traumatic brain injury includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
TBI
Head Injury
Concussion
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Key Information: ICD-10 Coding for Traumatic Brain Injury

Essential facts and insights about ICD-10 Coding for Traumatic Brain Injury

Use ICD-10 code S06.0X0A for concussion without loss of consciousness, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Concussion without loss of consciousness, initial encounter

Billable Code
S06.0X0A
Billable

Diagnostic Criteria

  • • Clinical diagnosis of concussion
  • • No loss of consciousness reported

Applicable To

  • • Mild traumatic brain injury

Important Notes

  • • Ensure documentation clearly states the absence of LOC.

Traumatic cerebral edema, initial encounter

Billable Code
S06.1X1A
Billable

Diagnostic Criteria

  • • CT or MRI showing cerebral edema
  • • History of head trauma

Applicable To

  • • Cerebral edema due to trauma

Important Notes

  • • Document imaging results to support the diagnosis.
Ancillary Codes

Additional codes that may be used with this diagnosis

R40.1

Coma scale

Use to document the level of consciousness if applicable.

R40.2

Coma scale

Use to document the level of consciousness if applicable.

Frequently Asked Questions

What is the ICD-10 code for a concussion without loss of consciousness?

The ICD-10 code for a concussion without loss of consciousness is S06.0X0A, used for initial encounters.

How do you code a traumatic brain injury with cerebral edema?

For a traumatic brain injury with cerebral edema, use ICD-10 code S06.1X1A for the initial encounter.

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