Radiology Coding Alert

An estimated 1.5 million people suffer a traumatic brain injury each year.

Before Oct. 1, 2021, you were limited to using traumatic brain injury (TBI) codes to report brain compression conditions. Now, with newly added traumatic brain compression codes and instructions, you can accurately report traumatic brain compression diagnoses and underlying conditions.

Check out our breakdown of the new codes and guidance.

What Are Brain Compression and Herniation?

Brain compression occurs when swelling or pooling fluid is present within a closed compartment within the brain. The buildup increases the pressure on the cells inside the compartment. The compartment is usually bound by bone or a rigid membrane, and the increased pressure can result in reduced blood flow (ischemia), which can cause ischemic tissue death.

The difference between the two traumatic brain compression subcategories is whether the patient presents brain herniation simultaneously with the compression. “Brain herniation occurs when tissue within one compartment is pushed into another,” says Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, of Poe Bernard Consulting in Salt Lake City, Utah.

Recognize Role of CT and the Glasgow Coma Scale

Since each location in the brain has a certain function, “providers have a very good idea exactly where a problem lies based on the signs and symptoms presented in the patient,” Bernard says. However, a computed tomography (CT) scan, such as 70450-70470 (Computed tomography, head or brain; …), helps confirm brain compression or herniation.

Providers can also use a Glasgow Coma Scale, coded using R40.24- (Glasgow coma scale, total score), to gauge the patient’s neurological status. The Glasgow Coma Scale is a 15-point test doctors and other qualified healthcare professionals (QHP) use to evaluate the initial severity of a brain injury. The provider asks the patient to follow directions and assesses how well the patient can move their extremities and eyes. The test may be repeated during the first few hours after the injury and a higher score correlates with less severe injuries. Note: The CPT^® code set doesn’t have a separate code for the Glasgow Coma Scale, as the assessment is part of the evaluation and management (E/M) service.

Understand Traumatic Brain Compression Codes

When you turn to the S06.- (Intracranial injury) category in Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) of the 2022 ICD-10-CM code set, you’ll find several subcategories pertaining to brain injuries.

Effective Oct. 1, 2021, the new traumatic brain compression codes are listed within subcategory S06.A- (Traumatic brain compression and herniation). This subcategory further divides into these two:

• S06.A0- (Traumatic brain compression without herniation)
• S06.A1- (Traumatic brain compression with herniation)

The codes cover diagnoses of traumatic brain compression with and without herniation and allow you to report the patient’s diagnosis with greater specificity than you could in the past. “What’s interesting to me is that we didn’t have these codes until October [2021]. Until then, we couldn’t report traumatic brain compression, only the compression seen in stroke or leak of cerebrospinal fluid in the brain,” Bernard says. Prior to the addition of the S06.A- codes, you were limited to S06.2- (Diffuse traumatic brain injury) or S06.3- (Focal traumatic brain injury) to report traumatic brain injuries.

7th character required: Several codes in Chapter 19 require 7th characters to be complete, and S06.A0- and S06.A1- are no different. However, the instructions for the 7th characters aren’t included at the subcategory level.

“You can always look to the beginning of the section to see if the codes need to have a 7th [character] or not,” says Jill M. Young, CPC, CEMC, CEDC, CIMC, of Young Medical Consulting LLC in East Lansing, Michigan. Under category S06.-, you’ll find instructions to choose from the following 7th characters when reporting the diagnosis:

• A = initial encounter
• D = subsequent encounter
• S = sequela

Additionally, you’ll need to include a placeholder “X” when you’re reporting a full traumatic brain compression code. Why? According to ICD-10-CM Official Guidelines, Section I.A.4, “The ‘X’ is used as a placeholder at certain codes to allow for future expansion.” Each traumatic brain compression subcategory reaches only five characters, and you’re required to include a 7th character, which means you’ll need to use a placeholder character to ensure the code becomes valid. For instance, note the multiple Xs in S02.2XXA (Fracture of nasal bones, initial encounter for closed fracture). ICD-10-CM code S02.2- (Fracture of nasal bones) features a 7th character required icon, so you need two placeholder characters to complete the code.

Code first notes: You’ll find code first instructions under subcategory code S06.A- that guide you to report the underlying traumatic brain injury before S06.A0- or S06.A1-. The code first codes include TBI codes S06.2- and S06.3- along with S06.5- (Traumatic subdural hemorrhage) and S06.6- (Traumatic subarachnoid hemorrhage).

Capture All the Codes in This TBI Scenario

Scenario: A patient presents to the emergency department (ED) after a fall at work. They fell and hit their head on the concrete floor and lost consciousness for about 45 minutes. The physician in the ED orders CT scans to evaluate the extent of the injury. After the procedure, the scan reveals the patient is experiencing traumatic brain compression with herniation as well as traumatic subdural hemorrhage.

For this scenario, you’ll choose the applicable traumatic brain compression code and use 7th character A to indicate the visit is an initial encounter since the patient presented to the ED. You’ll also need to assign the correct code from the S06.5- subcategory according to the S06.A- code first instructions. The 6th characters of the S06.5- code category cover whether the patient lost consciousness, how long the patient was unconscious, if the patient survived after regaining consciousness, and if the patient passed away during loss of consciousness.

In addition to presenting to the ED, the patient lost consciousness for 45 minutes, so you’ll choose S06.5X2A (Traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter). Then you’ll code the appropriate traumatic brain compression code, which is S06.A1XA (Traumatic brain compression with herniation, initial encounter) for this scenario.

Tracking Brain Compression Codes for Research

The Centers for Disease Control and Prevention (CDC) estimates approximately 223,050 people were hospitalized due to TBI-related injuries in 2018, while an estimated 60,611 people passed away from their injuries in 2019 (www.cdc.gov/traumaticbraininjury/data/index.html).

The traumatic brain compression codes are recent additions to the ICD-10-CM code set, but their addition will be beneficial to researchers in the future. The codes can provide “more specificity in the incidence and outcomes related to traumatic brain compression and herniation as part of traumatic brain injury research to advance care and rehabilitation of TBI patients,” Bernard says.