Brain injury, focal (TBI), injury/trauma
| ICD10 Diagnosis | |
| Dx: | Brain injury, focal (TBI), injury/trauma |
| ICD10 code: | S06.3 |
| Pre-ICD10 counterpart: | Subdural hemorrhage, Epidural hemorrhage, Subdural Hematoma - POST OP, Subdural Hematoma - NON POST OP, Other Bleeds/Skull |
| 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
- incl traumatic intracerebral hemorrhage
- Focal cerebral contusions are the most frequently encountered lesions. Contusions are commonly seen in the basal frontal and temporal areas, which are particularly susceptible due to direct impact on basal skull surfaces in the setting of acceleration/deceleration injuries
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
To code a TBI as a comorbid code: please see Brain/intracranial injury NOS, injury/trauma
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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