Concussion and Traumatic Brain Injury ICD-10-CM codes

Concussion is S06.0X- and the sixth character reports loss of consciousness: 0 without loss of consciousness (S06.0X0A), 1 with loss of consciousness of 30 minutes or less (S06.0X1A), 9 with loss of consciousness of unspecified duration (S06.0X9A), and A with loss of consciousness status unknown (S06.0XAA). The seventh character is A initial encounter, D subsequent encounter, or S sequela; intracranial injuries do not use the fracture characters. A concussion with a loss of consciousness longer than 30 minutes is not a concussion in ICD-10-CM and is coded to S06.9X- or the specific intracranial injury.

S06.9X- is unspecified intracranial injury and is where the index sends a head injury with loss of consciousness when no more specific injury is documented. Its sixth character grades the loss of consciousness in more detail (2 for 31 to 59 minutes, 3 for 1 hour to 5 hours 59 minutes, 4 for 6 to 24 hours, 5 and 6 for over 24 hours with and without return to the pre-existing level, 7 and 8 for death from the brain injury or another cause, 9 unspecified duration, A status unknown). A head injury without any documented intracranial injury or loss of consciousness is S09.90XA. When a concussion occurs with another intracranial injury such as a contusion or hemorrhage (S06.1- to S06.8-), code the specific injury and not S06.0X-.

Postconcussional syndrome (F07.81) is for symptoms that persist after the acute injury. It carries an Excludes1 note for a current concussion, so it is not reported with an S06.0X- code for the same episode; use it on later encounters with the S sequela character or on its own. A resolved traumatic brain injury is reported with Z87.820. Glasgow coma scale scores may be added with R40.24- codes (for example R40.2430 for a score of 3 to 8, unspecified time). Report the external cause (W19.XXXA fall, Y93.61 American tackle football) on the initial encounter.