Brain/intracranial injury NOS, injury/trauma
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| ICD10 Diagnosis | |
| Dx: | Brain/intracranial injury NOS, injury/trauma |
| ICD10 code: | S06.9 |
| Pre-ICD10 counterpart: | Concussion\Contusion, Subdural Hematoma - POST OP, Subdural Hematoma - NON POST OP, Other Bleeds/Skull, Other Trauma |
| Charlson/ALERT Scale: | none |
| APACHE Como Component: | none |
| APACHE Acute Component: | 2019-0: Head Trauma |
| Start Date: | |
| Stop Date: | |
| External ICD10 Documentation | |
This diagnosis is a part of ICD10 collection.
Additional Info
Includes:
- Includes TBI with residual deficits
- Regarding coding for residual consequences of an old brain trauma / TBI with residual deficits:
- As always, if the injury was old and FULLY resolved, with no ongoing sequelae, do not code it at all.
- If there are ongoing sequelae, then code those (e.g. cognitive impairment) and you can also combine the cognitive impairment code with this code, which is the mechanism of that cognitive impairment.
- Regarding coding for residual consequences of an old brain trauma / TBI with residual deficits:
Alternate ICD10s to consider coding instead or in addition
Candidate Combined ICD10 codes
Traumas and their Mechanisms
- In ICD10, traumas need to be combined with separate mechanism codes to fully explain the situation.
- Here are lists of the codes for "mechanical" injuries to various body parts:
- some codes are always traumatic and always need a mechanism:
- Other codes may or may not be of a traumatic nature; these also qualify to be coded with trauma mechanisms listed below:
| Potential trauma codes: |
- Here is a list of the external mechanism or agent that caused the trauma:
Regarding Multiple Trauma
- When a person has multiple body areas traumatized, code Multiple trauma
- When using Multiple trauma also code the individual things traumatized, e.g. leg, arm, head, etc.
- Code Multiple trauma and all the individual things traumatized as Combined ICD10 codes
- And in this case, assuming that they all have the same mechanism of injury (e.g. Mechanism of injury: motorcyclist), then you'd also code that Mechanism code as the same Combined ICD10 codes.
- If the multiple trauma is the primary admit diagnosis, then among this group of linked ICD10 codes, the Primary Admit Diagnosis would be either the Multiple trauma or the "worst" thing injured, e.g. Brain injury, diffuse (TBI), injury/trauma
Iatrogenic injuries
- Some iatrogenic codes are self-explanatory for what occurred. For example Iatrogenic, air embolism, as complication of line/infusion/transfusion/injection. But for others, such as Iatrogenic, puncture or laceration, related to a procedure or surgery NOS it's not clear what happened, i.e. what was iatrogenically injured.
- In these latter cases, with just one exception, DO NOT also code a trauma code for what was iatrogenically injured. This is because iatrogenic injuries are technically not considered to be traumas.
- that one exception is you should code Rib fracture(s) due to CPR in the context of CPR, cardiac resuscitation.
- Instead, combine the iatrogenic code with another ICD10 code indicating the body part involved.
- e.g. for iatrogenic laceration of a pulmonary artery, combine: Iatrogenic, puncture or laceration, related to a procedure or surgery NOS with Disorder of pulmonary vessels, NOS. See list of NOS codes in ICD10.
- In these latter cases, with just one exception, DO NOT also code a trauma code for what was iatrogenically injured. This is because iatrogenic injuries are technically not considered to be traumas.
Related CCI Codes
Data Integrity Checks (automatic list)
| App | Status | |
|---|---|---|
| Query check ICD10 mechanism vs trauma | CCMDB.accdb | implemented |
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