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2025 ICD-10-CM code S06.0X

Concussion; a minor brain injury from external force.

Use additional codes to specify the cause of injury (Chapter 20) and any retained foreign body (Z18.-). Code to the highest level of specificity possible.

Medical necessity for diagnostic testing and treatment is determined based on the severity of symptoms, presence of neurological deficits, and risk of complications.Referral to a neurosurgeon may be required in certain cases.

Diagnosis is based on patient history, physical exam (including Glasgow Coma Scale, pupil response), and imaging (X-rays, CT, MRI) as needed. Treatment may involve observation, rest, analgesics, and management of associated symptoms. Surgery is rare.

IMPORTANT:Use additional code(s) from Chapter 20 (External causes of morbidity) to indicate the cause of injury.If applicable, code any retained foreign body (Z18.-).Excludes birth trauma (P10-P15) and obstetric trauma (O70-O71).

In simple words: A concussion is a type of head injury that happens when your brain moves around inside your skull. It can cause symptoms like headache, dizziness, nausea, and confusion, but these usually go away after a short time. Doctors may use imaging tests like X-rays or MRIs to check for more serious injuries.

A concussion is a mild traumatic brain injury caused by an external force, such as a fall, motor vehicle accident, or blow to the head.It results in a temporary disruption of brain function, potentially affecting consciousness, awareness, and responsiveness. Symptoms can include headache, dizziness, nausea, vomiting, confusion, and visual disturbances. Diagnosis involves patient history, physical examination, Glasgow Coma Scale assessment, and potentially neuroimaging (X-rays, CT, MRI) and EEG.

Example 1: A 17-year-old soccer player sustains a concussion after a collision during a game.She experiences immediate headache, dizziness, and brief loss of consciousness.She is evaluated using the Glasgow Coma Scale and undergoes a CT scan to rule out intracranial hemorrhage.She is advised to rest and avoid physical activity for several days. , A 65-year-old man falls and hits his head at home. He presents to the emergency room with headache, confusion, and mild nausea several hours later. The physician orders a CT scan to rule out a skull fracture or intracranial bleeding, and an MRI to evaluate any soft tissue injury. He is kept for observation overnight., A 30-year-old woman is involved in a motor vehicle accident. She complains of severe headache and visual disturbances.A CT scan is performed and shows a mild cerebral concussion with no evidence of skull fracture or intracranial hemorrhage. She is treated conservatively with analgesics and close monitoring.

Detailed patient history including mechanism of injury, loss of consciousness (duration and presence/absence), and symptom onset and duration. Glasgow Coma Scale scores and physical examination findings.Neuroimaging reports (CT, MRI, X-ray) if performed. Treatment plan and response to treatment.

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