Neurosurgery Coding Alert

Reader Questions:

Answer Trauma Question, Then Code Brain Herniation

Question: Encounter notes indicate that the patient suffered a herniated brain stem. What is the ICD-10 code for this injury?

AAPC Forum Subscriber

Answer: Your diagnosis code choice will depend on whether the herniation was traumatic. For non-traumatic brain stem herniation, opt for G93.5 (Compression of brain). Per the synonyms under G93.5, use G93.5 for any of these diagnoses:

  • Herniation of brain stem
  • Arnold-Chari type I compression of brain
  • Compression of brain stem

If, however, the herniation is traumatic, you’ll opt for S06.A1- (Traumatic brain compression with herniation).


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