https://www.ncbi.nlm.nih.gov/books/NBK542610/
Examples of ICD-10-CM Codes Typically Associated with TBI
Acute Injuries
| Series Code | Description |
|---|---|
| S02.0xx | Fractures of vault of skull—requires a seventh character for type of encounter and healing |
| S02.1 | Fractures of base of skull—requires two digits and a seventh character |
| S06.0 | Concussion—requires two digits and a seventh character |
| S06.1 | Traumatic cerebral edema—requires two digits and a seventh character |
| S06.2 | Diffuse traumatic brain injury—requires two digits and a seventh character |
| S06.30 | Focal traumatic brain injury—requires an additional digit and a seventh character |
| S06.31 | Contusion and laceration of right cerebrum—requires an additional digit and a seventh character |
| S06.32 | Contusion and laceration of left cerebrum—requires an additional digit and a seventh character |
| S06.33 | Contusion and laceration of cerebrum, unspecified—requires an additional digit and a seventh character |
| S09.x | Unspecified intracranial injury (TBI NOS)—requires an additional digit and a seventh character |
Late Effect Codes or Sequela
| Series Code | Description |
|---|---|
| S06.2 | Diffuse traumatic brain injury—requires two digits and a seventh character of S |
| S06.30 | Focal traumatic brain injury—requires an additional digit and a seventh character of S |
| S09.x | Unspecified intracranial injury (TBI NOS)—requires an additional digit and a seventh character of S |
Symptoms Involving Emotional State
| ICD-10 Code | Symptom |
|---|---|
| R45.0 | Nervousness |
| R45.4 | Irritability and anger |
| R45.87 | Impulsiveness |
| R45.86 | Emotional lability |
| R45.3 | Demoralization and apathy |
| R45.89 | Other signs and symptoms involving emotional state |
Symptoms Involving Cognitive Function and Awareness
| ICD-10 Code | Symptom |
|---|---|
| R41.840 | Attention and concentration deficit |
| R41.841 | Cognitive communication deficit |
| R41.842 | Visuospatial deficit |
| R41.843 | Psychomotor deficit |
| R41.844 | Frontal lobe and executive function deficit |
| R41.89 | Other signs and symptoms involving cognitive functions and awareness |
Note: Memory deficits will be coded as R41.3.
Physical Effects of TBI
| ICD-10 Code | Description |
|---|---|
| G44.301 | Posttraumatic headache, unspecified, intractable |
| G44309 | Posttraumatic headache, unspecified, not intractable |
| G44.321 | Chronic posttraumatic headache, unspecified, intractable |
| G44.329 | Chronic posttraumatic headache, unspecified, not intractable |
| R42. | Dizziness |
| R43.0 | Loss of smell (anosmia) |
| R43.8 | Other disturbance of smell and taste |
| R47.82 | Fluency disorder conditions classified elsewhere |
| R47.81 | Slurred speech |
| R56.1 | Posttraumatic seizures |