Version 2024

2024 ICD-10-CM Diagnosis Code S06.2X0S

Diffuse traumatic brain injury without loss of consciousness, sequela

ICD-10-CM:: S06.2X0S
Short Description:: Diffuse TBI w/o loss of consciousness, sequela
Is Billable?: Yes - Valid for Submission
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Code Classification

Injury, poisoning and certain other consequences of external causes
(S00–T98)
- Injuries to the head
  (S00-S09)
  - Intracranial injury
    (S06)

S06.2X0S is a billable diagnosis code used to specify a medical diagnosis of diffuse traumatic brain injury without loss of consciousness, sequela. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

S06.2X0S is a sequela code, includes a 7th character and should be used for complications that arise as a direct result of a condition like diffuse traumatic brain injury without loss of consciousness. According to ICD-10-CM Guidelines a "sequela" code should be used for chronic or residual conditions that are complications of an initial acute disease, illness or injury. The most common sequela is pain. Usually, two diagnosis codes are needed when reporting sequela. The first code describes the nature of the sequela while the second code describes the sequela or late effect.

1. Approximate Synonyms
2. Coding Guidelines
3. Tabular List of Diseases and Injuries
4. Present on Admission (POA)
5. Convert to ICD-9 Code
6. Patient Education
7. Other Codes Used Similar Conditions
8. Code History

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

Brain injury without open intracranial wound AND with concussion
Cerebellar laceration with open intracranial wound
Cerebellar laceration with open intracranial wound AND no loss of consciousness
Cerebral hemorrhage due to trauma
Closed skull fracture with intracranial hemorrhage
Contusion of brain
Contusion of brain without open intracranial wound
Contusion of brain without open intracranial wound
Contusion of cerebral cortex
Contusion of cerebral cortex
Contusion of cerebral cortex
Contusion of cerebrum with open intracranial wound
Cortex contusion with open intracranial wound
Cortex contusion with open intracranial wound, with no loss of consciousness
Cortex contusion without open intracranial wound
Cortex contusion without open intracranial wound
Cortex contusion without open intracranial wound AND with concussion
Diffuse brain injury
Falx laceration
Hind brain laceration with open intracranial wound
Hind brain laceration with open intracranial wound, with no loss of consciousness
Laceration of brain
Laceration of brain with open intracranial wound
Open fracture of base of skull
Open fracture of base of skull with intracranial hemorrhage
Open skull fracture with intracranial hemorrhage
Perinatal occipital diastasis
Perinatal skull defect
Traumatic brain injury with no loss of consciousness
Traumatic brain injury with no loss of consciousness

Coding Guidelines

The appropriate 7th character is to be added to each code from block Intracranial injury (S06). Use the following options for the aplicable episode of care:

A - initial encounter
D - subsequent encounter
S - sequela

Present on Admission (POA)

S06.2X0S is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA Indicator	Reason for Code	CMS will pay the CC/MCC DRG?
Y	Diagnosis was present at time of inpatient admission.	YES
N	Diagnosis was not present at time of inpatient admission.	NO
U	Documentation insufficient to determine if the condition was present at the time of inpatient admission.	NO
W	Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.	YES
1	Unreported/Not used - Exempt from POA reporting.	NO

Convert to ICD-9-CM Code

Source ICD-10-CM Code		Target ICD-9-CM Code
S06.2X0S		907.0 - Lt eff intracranial inj
Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education

Traumatic Brain Injury

What is traumatic brain injury (TBI)?

Traumatic brain injury (TBI) is a sudden injury that causes damage to the brain. It may happen when there is a blow, bump, or jolt to the head. This is a closed head injury. A TBI can also happen when an object penetrates the skull. This is a penetrating injury.

Symptoms of a TBI can be mild, moderate, or severe. Concussions are a type of mild TBI. The effects of a concussion can sometimes be serious, but most people completely recover in time. More severe TBI can lead to serious physical and psychological symptoms, coma, and even death.

What causes traumatic brain injury (TBI)?

The main causes of TBI depend on the type of head injury:

Some of the common causes of a closed head injury include
- Falls. This is the most common cause in adults age 65 and older.
- Motor vehicle crashes. This is the most common cause in young adults.
- Sports injuries
- Being struck by an object
- Child abuse. This is the most common cause in children under age 4.
- Blast injuries due to explosions
Some of the common causes of a penetrating injury include
- Being hit by a bullet or shrapnel
- Being hit by a weapon such as a hammer, knife, or baseball bat
- A head injury that causes a bone fragment to penetrate the skull

Some accidents such as explosions, natural disasters, or other extreme events can cause both closed and penetrating TBI in the same person.

Who is at risk for traumatic brain injury (TBI)?

Certain groups are at higher risk of TBI:

Men are more likely to get a TBI than women. They are also more likely to have serious TBI.
Adults aged 65 and older are at the greatest risk for being hospitalized and dying from a TBI

What are the symptoms of traumatic brain injury (TBI)?

The symptoms of TBI depend on the type of injury and how serious the brain damage is.

The symptoms of mild TBI can include:

A brief loss of consciousness in some cases. However, many people with mild TBI remain conscious after the injury.
Headache
Confusion
Lightheadedness
Dizziness
Blurred vision or tired eyes
Ringing in the ears
Bad taste in the mouth
Fatigue or lethargy
A change in sleep patterns
Behavioral or mood changes
Trouble with memory, concentration, attention, or thinking

If you have a moderate or severe TBI, you may have those same symptoms. You may also have other symptoms such as:

A headache that gets worse or does not go away
Repeated vomiting or nausea
Convulsions or seizures
Not being able to wake up from sleep
Larger than normal pupil (dark center) of one or both eyes. This is called dilation of the pupil.
Slurred speech
Weakness or numbness in the arms and legs
Loss of coordination
Increased confusion, restlessness, or agitation

How is traumatic brain injury (TBI) diagnosed?

If you have a head injury or other trauma that may have caused a TBI, you need to get medical care as soon as possible. To make a diagnosis, your health care provider:

Will ask about your symptoms and the details of your injury
Will do a neurologic exam
May do imaging tests, such as a CT scan or MRI
May use a tool such as the Glasgow coma scale to determine how severe the TBI is. This scale measures your ability to open your eyes, speak, and move.
May do neuropsychological tests to check how your brain is functioning

What are the treatments for traumatic brain injury (TBI)?

The treatments for TBI depend on many factors, including the size, severity, and location of the brain injury.

For mild TBI, the main treatment is rest. If you have a headache, you can try taking over-the-counter pain relievers. It is important to follow your health care provider's instructions for complete rest and a gradual return to your normal activities. If you start doing too much too soon, it may take longer to recover. Contact your provider if your symptoms are not getting better or if you have new symptoms.

For moderate to severe TBI, the first thing health care providers will do is stabilize you to prevent further injury. They will manage your blood pressure, check the pressure inside your skull, and make sure that there is enough blood and oxygen getting to your brain.

Once you are stable, the treatments may include:

Surgery to reduce additional damage to your brain, for example to
- Remove hematomas (clotted blood)
- Get rid of damaged or dead brain tissue
- Repair skull fractures
- Relieve pressure in the skull
Medicines to treat the symptoms of TBI and to lower some of the risks associated with it, such as
- Anti-anxiety medication to lessen feelings of nervousness and fear
- Anticoagulants to prevent blood clots
- Anticonvulsants to prevent seizures
- Antidepressants to treat symptoms of depression and mood instability
- Muscle relaxants to reduce muscle spasms
- Stimulants to increase alertness and attention
Rehabilitation therapies, which can include therapies for physical, emotional, and cognitive difficulties:
- Physical therapy, to build physical strength, coordination, and flexibility
- Occupational therapy, to help you learn or relearn how to perform daily tasks, such as getting dressed, cooking, and bathing
- Speech therapy, to help you to with speech and other communication skills and treat swallowing disorders
- Psychological counseling, to help you learn coping skills, work on relationships, and improve your emotional well-being
- Vocational counseling, which focuses on your ability to return to work and deal with workplace challenges
- Cognitive therapy, to improve your memory, attention, perception, learning, planning, and judgment

Some people with TBI may have permanent disabilities. A TBI can also put you at risk for other health problems such as anxiety, depression, and post-traumatic stress disorder. Treating these problems can improve your quality of life.

Can traumatic brain injury (TBI) be prevented?

There are steps you can take to prevent head injuries and TBIs:

Always wear your seatbelt and use car seats and booster seats for children
Never drive under the influence of drugs or alcohol
Wear a properly fitting helmet when riding a bicycle, skateboarding, and playing sports like hockey and football
Prevent falls by
- Making your house safer. For example, you can install railings on the stairs and grab bars in the tub, get rid of tripping hazards, and use window guards and stair safety gates for young children.
- Improving your balance and strength with regular physical activity

[Learn More in MedlinePlus]

Other ICD-10-CM Codes Commonly Used for Similar Conditions

Filter related codes list:

S06 Intracranial injury.
S06.0 Concussion.
S06.0X Concussion.
S06.0X0 Concussion without loss of consciousness.
S06.0X0A Concussion without loss of consciousness, initial encounter.
S06.0X0D Concussion without loss of consciousness, subsequent encounter.
S06.0X0S Concussion without loss of consciousness, sequela.
S06.0X1 Concussion with loss of consciousness of 30 minutes or less.
S06.0X1A Concussion with loss of consciousness of 30 minutes or less, initial encounter.
S06.0X1D Concussion with loss of consciousness of 30 minutes or less, subsequent encounter.
S06.0X1S Concussion with loss of consciousness of 30 minutes or less, sequela.
S06.0X9 Concussion with loss of consciousness of unspecified duration.
S06.0X9A Concussion with loss of consciousness of unspecified duration, initial encounter.
S06.0X9D Concussion with loss of consciousness of unspecified duration, subsequent encounter.
S06.0X9S Concussion with loss of consciousness of unspecified duration, sequela.
S06.0XA Concussion with loss of consciousness status unknown.
S06.0XAA Concussion with loss of consciousness status unknown, initial encounter.
S06.0XAD Concussion with loss of consciousness status unknown, subsequent encounter.
S06.0XAS Concussion with loss of consciousness status unknown, sequela.
S06.1 Traumatic cerebral edema.
S06.1X Traumatic cerebral edema.
S06.1X0 Traumatic cerebral edema without loss of consciousness.
S06.1X0A Traumatic cerebral edema without loss of consciousness, initial encounter.
S06.1X0D Traumatic cerebral edema without loss of consciousness, subsequent encounter.
S06.1X0S Traumatic cerebral edema without loss of consciousness, sequela.
S06.1X1 Traumatic cerebral edema with loss of consciousness of 30 minutes or less.
S06.1X1A Traumatic cerebral edema with loss of consciousness of 30 minutes or less, initial encounter.
S06.1X1D Traumatic cerebral edema with loss of consciousness of 30 minutes or less, subsequent encounter.
S06.1X1S Traumatic cerebral edema with loss of consciousness of 30 minutes or less, sequela.
S06.1X2 Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes.
S06.1X2A Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, initial encounter.
S06.1X2D Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, subsequent encounter.
S06.1X2S Traumatic cerebral edema with loss of consciousness of 31 minutes to 59 minutes, sequela.
S06.1X3 Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes.
S06.1X3A Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter.
S06.1X3D Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, subsequent encounter.
S06.1X3S Traumatic cerebral edema with loss of consciousness of 1 hour to 5 hours 59 minutes, sequela.
S06.1X4 Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours.
S06.1X4A Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, initial encounter.
S06.1X4D Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, subsequent encounter.
S06.1X4S Traumatic cerebral edema with loss of consciousness of 6 hours to 24 hours, sequela.
S06.1X5 Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level.
S06.1X5A Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter.
S06.1X5D Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, subsequent encounter.
S06.1X5S Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, sequela.
S06.1X6 Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving.
S06.1X6A Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter.
S06.1X6D Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, subsequent encounter.
S06.1X6S Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, sequela.
S06.1X7 Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness.
S06.1X7A Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter.

Code History

FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.