2025 ICD-10-CM code S06.2
Diffuse traumatic brain injury. Diffuse axonal brain injury.
The ICD-10-CM code S06.2 does not have any applicable modifiers.
Medical necessity for the evaluation and treatment of diffuse traumatic brain injury is established by the presence of signs, symptoms, and diagnostic findings consistent with the condition following a traumatic event.
Clinicians diagnose diffuse traumatic brain injury based on the patient's trauma history, physical exam (including response to stimuli and pupil dilation), Glasgow Coma Scale, imaging (CT, MRI), evoked potentials, and EEG. Treatment includes medication (sedatives, analgesics, corticosteroids, antiseizure drugs), stabilizing airway and circulation, immobilizing the neck or head, treating related problems, and physical and occupational therapy.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S06 - Traumatic brain injuryS06.2 - Diffuse traumatic brain injury
In simple words: Diffuse traumatic brain injury is a brain injury caused by forces that make the brain move back and forth inside the skull. This can happen in car accidents, sports injuries, or falls. It can damage many areas of the brain and change a person's consciousness.
Diffuse traumatic brain injury. Diffuse axonal brain injury. Use additional code, if applicable, for traumatic brain compression or herniation (S06.A-). Excludes1: traumatic diffuse cerebral edema (S06.1X-).
Example 1: A patient is brought to the ER after a motor vehicle accident. Imaging reveals diffuse axonal injury. Code S06.2 is assigned., A football player suffers a concussion with loss of consciousness and subsequent cognitive impairment. After extensive neurological assessment, diffuse traumatic brain injury is diagnosed. Code S06.2 is used., An elderly individual falls and sustains a head injury. They exhibit confusion and altered mental status. Imaging confirms diffuse brain injury, but there's no evidence of focal lesions or hematomas. S06.2 is assigned.
Documentation should include details of the traumatic event, neurological examination findings (including Glasgow Coma Scale score), results of imaging studies (CT, MRI), and evidence of diffuse brain injury.
- Specialties:Neurology, Neurosurgery, Emergency Medicine, Trauma Surgery
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office