Traumatic Brain Injury ICD-10-CM Codes

What ICD-10 Codes are Used for Traumatic Brain Injury? 

Here’s a list of the traumatic brain injury ICD codes you can use for medical billing and coding: 

• S06.2X: Diffuse traumatic brain injury 

Note: There are more specific ICD-10 codes under S06.2X that specify the duration of the patient’s loss of consciousness due to brain injury. 

• S06.30: Unspecified focal traumatic brain injury 

Note: There are more specific ICD-10 codes under S06.30 that specify the duration of the patient’s loss of consciousness due to the brain injury 

• S06.9X: Unspecified intracranial injury 

Note: There are more specific ICD-10 codes under S06.9X that specify the duration of the patient’s loss of consciousness due to the intracranial injury. 

In addition, before coding, consider if the brain injury and its code is an initial encounter, subsequent encounter, or sequela. Knowing these will help you choose and utilize the corresponding ICD-10 codes more accurately. 

Which Traumatic Brain Injury ICD codes are Billable? 

Only the more specific versions of the traumatic brain injury ICD-10 codes mentioned above are billable. 

Clinical Information

• Traumatic brain injury, also known as TBI, is when the brain gets damaged due to a bump, blow, jolt, or stab to the brain or body. 
• When a patient gets a traumatic brain injury, it can affect their brain function temporarily short-term - their thoughts, behaviors, actions, etc. - or, in extreme cases, long-term, which may result in a permanent disability or death. 
• Injuries may be primary or secondary. The difference between the two is, for the former, the damage affects the brain immediately. Meanwhile, for the latter, the damage can be seen over a period of time. 
• In addition, there are two types of TBI. The first one is a penetrating TBI, or open TBI, wherein the object pierces the skull and damages a part of the brain. On the other hand, the second one is non-penetrating TBI, or blunt TBI, wherein a solid external force moves the brain inside the skull. 
• There are numerous symptoms of traumatic brain injury. Some may experience changes in their physical, cognitive, and behavioral states. To enumerate, common signs and symptoms are headaches, disorientation, seizures, nausea, frustration, blurred vision, dizziness, sensitivity to light/sound, or fatigue/drowsiness. 
• Probable effects of a traumatic brain injury are damage to white matter in the brain, concussion, hematomas, contusions, skull fractures, post-traumatic dementia, swelling, and infections. 
• Common causes of traumatic brain injuries are falls, blunt trauma, assaults, vehicular accidents, and explosions. 
• A practitioner will have the patient undergo imaging and neuropsychological tests to diagnose traumatic brain injury. 
• Treatment will vary depending on the severity of the damage, but some standard treatments are medications, surgery, and rehabilitation. 

Synonyms Include:

• Focal brain injury
• Brain injury without open intracranial wound AND with a concussion
• Diffuse brain injury
• Traumatic brain injury with no loss of consciousness
• Intracranial injury