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ICD-10 Coding for Closed Head Trauma(S06.0X0A, S06.1X0A)

Complete ICD-10-CM coding and documentation guide for Closed Head Trauma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Blunt Head InjuryNon-Penetrating Head Injury

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Related ICD-10 Code Ranges

Complete code families applicable to Closed Head Trauma

S06.0-S06.9Primary Range

Intracranial injury

This range covers various types of intracranial injuries including concussions, cerebral edema, and traumatic brain injuries without open wounds.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S06.0X0AConcussion without loss of consciousness, initial encounterUse when a patient has a concussion without any loss of consciousness.
  • Documented absence of LOC
  • Negative CT scan
  • GCS 15 at 4 hours post-injury
S06.1X0ATraumatic cerebral edema without loss of consciousness, initial encounterUse when cerebral edema is confirmed by imaging and there is no LOC.
  • Radiologist confirmation of cerebral edema
  • No skull fracture

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for closed head trauma

Essential facts and insights about Closed Head Trauma

The ICD-10 code for closed head trauma without loss of consciousness is S06.0X0A.

Primary ICD-10-CM Codes for closed head trauma

S06.0X0A
Concussion without loss of consciousness, initial encounter
Billable Code

Decision Criteria

clinical Criteria

  • Patient presents with a concussion but no loss of consciousness.

Applicable To

  • Concussion without LOC

Excludes

  • Concussion with LOC

Clinical Validation Requirements

  • Documented absence of LOC
  • Negative CT scan
  • GCS 15 at 4 hours post-injury

Code-Specific Risks

  • Misclassification if LOC is not properly documented

Coding Notes

  • Ensure that the documentation clearly states the absence of LOC to avoid misclassification.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Car occupant injured in collision with fixed or stationary object, sequela

V43.52XS
Use to describe the external cause of injury in motor vehicle accidents.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Concussion with loss of consciousness of 30 minutes or less, initial encounter

S06.0X1A
Use if LOC is documented as 30 minutes or less.

Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter

S06.1X1A
Use if LOC is documented as 30 minutes or less.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Closed Head Trauma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S06.0X0A.

Impact

Clinical: Leads to misdiagnosis and incorrect treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials.

Mitigation Strategy

Use specific terms like 'concussion' or 'cerebral edema'., Include detailed injury mechanism.

Impact

Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.

Mitigation Strategy

Use S06.0X0A if there is no LOC.

Impact

Failure to accurately document LOC can lead to incorrect coding.

Mitigation Strategy

Implement a checklist for documenting LOC details.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Closed Head Trauma, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Closed Head Trauma

Use these documentation templates to ensure complete and accurate documentation for Closed Head Trauma. These templates include all required elements for proper coding and billing.

Concussion without LOC

Specialty: Emergency Medicine

Required Elements

  • Mechanism of injury
  • GCS score
  • Imaging results
  • Neurological exam findings

Example Documentation

Patient presented with a fall from a height. GCS 15 at 2 hours post-injury. CT scan negative for acute findings. No LOC reported.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient had a head injury.
Good Documentation Example
Patient sustained a fall from a height with no LOC. GCS 15 at 2 hours. CT negative.
Explanation
The good example provides specific details necessary for accurate coding.

Need help with ICD-10 coding for Closed Head Trauma? Ask your questions below.

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