ICD-10 Coding for Diffuse Axonal Injury(S06.2X5, S06.2X6)
Complete ICD-10-CM coding and documentation guide for Diffuse Axonal Injury. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Diffuse Axonal Injury
S06.2XPrimary Range
Diffuse traumatic brain injury
This range includes codes for diffuse axonal injury with various levels of consciousness.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S06.2X5 | Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level | Use when LOC >24h and patient returns to baseline consciousness. |
|
| S06.2X6 | Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level | Use when LOC >24h and patient does not return to baseline consciousness. |
|
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 diffuse axonal injury
Essential facts and insights about Diffuse Axonal Injury
Primary ICD-10-CM Codes for diffuse axonal injury
Decision Criteria
clinical Criteria
- Patient regains consciousness after LOC >24h
Applicable To
- DAI with LOC >24h, regained consciousness
Excludes
- DAI without LOC
- DAI with death prior to consciousness
Clinical Validation Requirements
- GCS ≤8 at admission
- MRI showing corpus callosum/brainstem lesions
Code-Specific Risks
- Undercoding if LOC duration is not specified
- Overcoding if consciousness return is not documented
Coding Notes
- Ensure LOC duration and consciousness return are clearly documented.
S06.2X6 - Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level
Use when LOC >24h and patient does not return to baseline consciousness.
Applicable To
- DAI with persistent vegetative state
Excludes
- DAI with LOC <24h
- DAI with consciousness return
Clinical Validation Requirements
- Persistent vegetative state
- Adams Grade 3 DAI on imaging
Coding Notes
Document vegetative state and lack of consciousness return.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Diffuse traumatic brain injury with loss of consciousness greater than 24 hours without return to pre-existing conscious level
S06.2X6Diffuse traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level
S06.2X5Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Diffuse Axonal Injury to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S06.2X5.
Impact
Clinical: Inaccurate patient status reporting, Regulatory: Non-compliance with coding standards, Financial: Potential reimbursement loss
Mitigation Strategy
Include consciousness status in discharge summary, Regularly update LOC status in patient record
Impact
Reimbursement: Potential underpayment due to incorrect DRG assignment, Compliance: Risk of audit failure due to inaccurate coding, Data Quality: Decreased accuracy in clinical data reporting
Mitigation Strategy
Always document and code the exact LOC duration.
Impact
Inadequate documentation of LOC duration and consciousness return
Mitigation Strategy
Implement standardized documentation templates
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 Diffuse Axonal Injury, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Diffuse Axonal Injury
Use these documentation templates to ensure complete and accurate documentation for Diffuse Axonal Injury. These templates include all required elements for proper coding and billing.
Neurology Progress Note
Specialty: NeurologyRequired Elements
- Mechanism of injury
- Consciousness duration
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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