Brain injury, diffuse (TBI), injury/trauma

ICD10 Diagnosis
Dx:	Brain injury, diffuse (TBI), injury/trauma
ICD10 code:	S06.2
Pre-ICD10 counterpart:	Diffuse axonal injury
Charlson/ALERT Scale:	none
APACHE Como Component:	none
APACHE Acute Component:	2019-0: Head Trauma
Start Date:
Stop Date:
External ICD10 Documentation	ICD-10 CM Wikipedia ICD-10 Wikipedia WHO ICD10 documentation ICD10data.com

This diagnosis is a part of ICD10 collection.

• SMW
  • 2019-01-01
  • 2999-12-31
  • S06.2

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Additional Info

Includes:

• diffuse traumatic brain injury (TBI)
• herniation related to the TBI
• diffuse axonal injury (DAI)
• anoxic brain injury due to hanging
  • Shearing mechanisms lead to DAI, which is visualized pathologically and on neuroimaging studies as multiple small lesions seen within white matter tracts . Patients with severe DAI typically present with profound coma without elevated intracranial pressure (ICP), and often have poor outcome.

Herniation

This dx includes herniation related to the TBI. For non-traumatically induced herniation, use Brain compression, including herniation instead.

As a Comorbid Diagnosis

To code a TBI as a comorbid code use Brain/intracranial injury NOS, injury/trauma.

Causes of TBI

The six categories of external force that may result in TBI include:

• The head being struck by an object
• The head striking an object
• Acceleration/deceleration of the brain without direct external impact
• A foreign body penetrating the brain
• The force from a blast/explosion
• Other forces yet to be defined

Alternate ICD10s to consider coding instead or in addition

• Brain death
• Anoxic brain injury, NOS

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:

Lightning injury Respiratory tract, foreign body in

• 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.

Related CCI Codes

Data Integrity Checks (automatic list)

	App	Status
Query check ICD10 mechanism vs trauma	CCMDB.accdb	implemented

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ENT	Testing Imaging	Cardiovascular Aneurysm Aortic Aneurysm Arrhythmia Arterial thromboembolism Atherosclerosis Cardiac septum problem Cerebral Hemorrhage/Stroke Heart valve disease Hemorrhage Hypertension Hypotension Ischemia Ischemic gut Ischemic heart disease Myocardial Infarction Pulmonary embolism Pulmonary hypertension Vasculitis Venous thromboembolism	Hereditary/congenital
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Misc Adverse effect Alcohol related Allergy Anesthetic related Antidepressant related Awaiting/delayed transfer COVID Cannabis related Cocaine related Decubitus ulcer Diagnosis implying death Exposure Fistula Hallucinogen related Has one Healthcare contact Hemorrhage Iatrogenic Metabolic/nutrition Non-traumatic fracture Observation Organ removal Ostomy Overdose Paralysis Past medical history Poisoning Psychoactive substance NOS related Radiation related Retired Code Rheumatic disease Sedative related Shock Solvent related Spine Stimulant related Transplant	Reproductive Abortion Breast disease Female genital neoplasm Male genital neoplasm Peripartum	Gastrointestinal Cirrhosis GI ulcer Gastroenteritis Gastrointestinal neoplasm Hepatitis Hernia Inflammatory Bowel Disease Intra-abdominal infection Ischemic gut Liver disease Liver failure Pancreas disease Pancreatitis Peptic ulcer	Musculoskeletal/soft tissue Hernia Joint/ligament trauma Muscle problem Muscles/tendon trauma Musculoskeletal/soft tissue neoplasm Osteomyelitis
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ICD10 Categories: ANCA-associated Vasculitis (AAV), Abdominal trauma, Abortion, Acute intoxication, Addiction, Adrenal Insufficiency, Adverse effect, Alcohol related, Allergy, Anemia, Anesthetic related, Aneurysm, Antibiotic resistance, Antidepressant related, Aortic Aneurysm, Arrhythmia, Arterial thromboembolism, Asthma, Atherosclerosis, Awaiting/delayed transfer, Bacteria, Benign neoplasm, Breast disease, Burn, COVID, Cannabis related, Cardiac septum problem, Cardiovascular, Cerebral Hemorrhage/Stroke, Chemical burn, Chronic kidney disease, Cirrhosis, Cocaine related, Decubitus ulcer, Delirium, Dementia, Diabetes, Diagnosis implying death, Double duty pathogen, ENT, Encephalitis, Encephalopathy, Endocrine disorder, Endocrine neoplasm, Exposure, Eye, Female genital neoplasm, Fistula, Fracture, Fungus, GI ulcer, Gastroenteritis, Gastrointestinal, Gastrointestinal neoplasm, Hallucinogen related, Has one, Head trauma, Head trauma (old), Healthcare contact, Heart valve disease, Heme/immunology, Heme/immunology neoplasm, Hemophilia, Hemorrhage, Hepatitis, Hereditary/congenital, Hernia, Hypertension, Hypotension, Iatrogenic, Iatrogenic infection, Iatrogenic mechanism, Imaging, Infection requiring pathogen, Infection with implied pathogen, Infectious disease, Inflammatory Bowel Disease, Influenza, Inhalation, Intra-abdominal infection, Ischemia, Ischemic gut, Ischemic heart disease, Joint/ligament trauma, Leukemia, Liver disease, Liver failure, Lower limb trauma, Lower respiratory tract infection, Lymphoma, Male genital neoplasm, Mechanism, Meningitis, Metabolic/nutrition, Metastasis, Misc, Muscle problem, Muscles/tendon trauma, Musculoskeletal/soft tissue, Musculoskeletal/soft tissue neoplasm... further results