2025 ICD-10-CM code S06
Intracranial injury. Traumatic brain injury.
Medical necessity for S06 is established by the presence of signs, symptoms, and diagnostic findings consistent with intracranial injury due to an external cause. This may include neurological deficits, altered consciousness, imaging findings of brain injury.
Providers diagnose intracranial injury based on patient history of trauma, physical exam (response to stimuli, pupil dilation), Glasgow Coma Scale, imaging (X-ray, CT, MRI), and EEG. Treatment includes medications (sedatives, analgesics, antiseizure drugs), stabilizing airway and circulation, immobilization, treating associated problems, and surgery (ICP monitor, subdural hematoma evacuation).
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: A brain injury caused by an outside force like a hit to the head. It can range from mild concussions to severe damage.
Intracranial injury, also known as traumatic brain injury, refers to damage to the brain’s tissues by an external force, which may occur due to falls, motor vehicle accidents, or blow to the head. This affects brain function and can cause a possible change in the state of consciousness, or level of awareness and responsiveness.
Example 1: A patient falls from a ladder and hits their head, resulting in a loss of consciousness and confusion. CT scan reveals intracranial bleeding. This would be coded as S06., A pedestrian is struck by a car and suffers a blow to the head. They experience disorientation, memory problems, and blurred vision. This could be classified under S06., An athlete receives a concussion during a sports game, resulting in dizziness, headache, and nausea. This would fall under S06.
Documentation should include details of the traumatic event, neurological examination findings (including Glasgow Coma Scale), imaging results (CT, MRI), and any other diagnostic tests performed (EEG).Details of any associated injuries like open wounds (S01.-) or skull fractures (S02.-) should also be documented.
** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). Excludes2: burns and corrosions (T20-T32), effects of foreign body in ear (T16), effects of foreign body in larynx (T17.3), effects of foreign body in mouth NOS (T18.0), effects of foreign body in nose (T17.0-T17.1), effects of foreign body in pharynx (T17.2), effects of foreign body on external eye (T15.-), frostbite (T33-T34), insect bite or sting, venomous (T63.4).
- Specialties:Neurosurgery, Emergency Medicine, Trauma Surgery
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office