Brain Injuries

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Brain Injuries: Traumatic or Not?

Cerebral edema, brain compression and herniation are significant complications that may occur with brain injury or pathology.

When these findings are present, the provider should document the following:

  • Etiology: trauma, stroke, subarachnoid hemorrhage, brain tumor, etc.
  • Associated complications: cerebral edema, brain compression, herniation
    • These findings cannot be coded from the radiology report
    • The clinician must document in the note
  • Traumatic
    • There are distinct ICD-10 codes for brain compression/herniation related to trauma
    • A traumatic brain injury cannot be assumed based on the history of present illness or mechanism of injury e.g., the patient was in a car accident
  • Documentation examples
    • “Traumatic brain injury with cerebral edema”
    • “Traumatic brain injury from MVA complicated by cerebral edema, brain compression and herniation”
    • “Metastatic small cell cancer to the brain with brain compression”

Download the complete tip, Brain Injuries.