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2025 ICD-10-CM code S06.1

Traumatic cerebral edema is swelling of the brain due to head trauma.

Code also for any associated infection.Use additional code to identify any retained foreign body, if applicable (Z18.-).Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate the cause of injury. Codes within the T section that include the external cause do not require an additional external cause code.

Medical necessity for diagnosis and treatment is established based on the severity of cerebral edema, the presence of neurological symptoms indicating compromised brain function, and the need for interventions to reduce intracranial pressure and prevent further neurological damage or death. The documentation must support the medical necessity.

Providers diagnose and treat traumatic cerebral edema based on patient history, physical examination (including Glasgow Coma Scale), imaging (X-rays, CT, MRI), and electroencephalography (EEG). Treatment may include medication (corticosteroids, analgesics, anti-seizure), airway/circulatory stabilization, head/neck immobilization, management of related problems, and potentially surgery.

IMPORTANT:Use additional codes to specify associated infections (if any) and retained foreign bodies (Z18.-).Secondary codes from Chapter 20 (External causes of morbidity) should be used to indicate the cause of injury.Codes in the T-section that include the external cause do not require an additional external cause code.

In simple words: Traumatic cerebral edema is brain swelling caused by a head injury. This swelling can make it hard to think clearly, stay awake, or respond normally. Doctors use tests like CT scans and MRIs to see the swelling and decide how to treat it.Treatment might include medicine to reduce swelling and pressure, or even surgery.

Traumatic cerebral edema refers to the accumulation of fluid within the brain's cellular spaces following head trauma, such as falls, motor vehicle accidents, or blows to the head. This condition impairs brain function, potentially leading to altered consciousness, decreased responsiveness, and various neurological symptoms.Diagnosis involves evaluating the patient's history, performing a physical examination (including Glasgow Coma Scale assessment), and utilizing imaging techniques like X-rays, computed tomography (CT) angiography, and magnetic resonance imaging (MRI) angiography to assess the extent of damage. Treatment may involve medications (corticosteroids, analgesics, antiseizure drugs), airway and circulatory stabilization, head/neck immobilization, management of associated issues, and potentially surgical intervention (e.g., ICP monitoring, ICP relief).

Example 1: A patient presents after a motor vehicle accident with altered consciousness, headache, and vomiting. CT scan reveals diffuse cerebral edema. Treatment includes intravenous corticosteroids, close neurological monitoring, and supportive care., A child falls and sustains a skull fracture with resultant focal cerebral edema.Surgical intervention is required to evacuate hematoma and relieve pressure. Post-operative care includes monitoring for seizure activity and managing cerebral edema., An athlete suffers a concussion during a sports game, leading to mild cerebral edema. The patient experiences headaches and dizziness for several days, receiving conservative management with close observation and medication for pain relief.

Detailed patient history including mechanism of injury, Glasgow Coma Scale score at presentation, neurological examination findings, imaging reports (CT, MRI), and any laboratory results. Documentation of treatment plan including medications administered, surgical procedures (if performed), and progress notes detailing clinical response to treatment.

** The severity of traumatic cerebral edema can vary widely, ranging from mild to life-threatening.Appropriate treatment and prognosis depend significantly on the cause, location, and extent of the edema. Close monitoring of intracranial pressure (ICP) is critical in severe cases.The information provided here is for general knowledge and should not be considered medical advice.

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