2025 ICD-10-CM code S06.9
Unspecified intracranial injury.
The 7th character should be used to specify the encounter (A = initial encounter, D = subsequent encounter, S = sequela).
Medical necessity is established by the presence of signs, symptoms, or diagnostic findings consistent with an intracranial injury. The documentation should support the need for the diagnostic tests and treatments provided.
Clinicians diagnose unspecified intracranial injury based on patient history of trauma, physical examination, and imaging (X-rays, CT, CTA, MRI, EEG). Treatment can range from critical care management and medication (analgesics, diuretics, antiseizure drugs) to surgical intervention for severe cases.Long-term care depends on the patient's prognosis.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: An unspecified intracranial injury is an injury to the brain from various causes, such as falls, accidents, or blows to the head.It can lead to problems with brain function and consciousness. The specific type of injury is not documented.
Unspecified intracranial injury. Includes: Brain injury NOS, Head injury NOS with loss of consciousness, Traumatic brain injury NOS. Excludes1: conditions classifiable to S06.0- to S06.8- (code to specified intracranial injury), head injury NOS (S09.90)
Example 1: A patient arrives at the ER after a car accident with loss of consciousness but no other obvious head injuries.Imaging reveals an unspecified intracranial injury., A patient falls from a ladder and experiences a period of confusion. After examination and imaging, the physician diagnoses an unspecified intracranial injury., An athlete receives a blow to the head during a game and exhibits signs of a concussion, but the precise nature of the intracranial injury is not immediately clear. This would be coded as S06.9 until a more specific diagnosis can be made.
Documentation should include details of the trauma, clinical presentation (e.g., loss of consciousness, confusion, neurological deficits), and results of any imaging studies.
- Specialties:Emergency Medicine, Neurology, Neurosurgery, Trauma Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Office