ICD 10 CM S06.313A | Description & Clinical Information

ICD 10 S06.313A describes a specific medical condition characterized by the presence of blood accumulation and a tear in the tissue of the right cerebrum, which is the largest part of the brain, resulting from a traumatic brain injury or deceleration injury, such as when the head comes into contact with a solid object during a motor vehicle collision, and can lead to altered awareness and responsiveness to stimuli, and is applicable to the initial encounter for contusion and laceration with loss of consciousness for 1 hour to 5 hours 59 minutes.

Official Description Of S06.313A

The ICD 10 CM book defines ICD 10 code S06.313A as:

Contusion and laceration of right cerebrum with loss of consciousness of 1 hour to 5 hours 59 minutes, initial encounter
Parent Code Notes: S06.3

Excludes1: any condition classifiable to S06.4-S06.6

Excludes2: focal cerebral edema (S06.1)

Use additional code, if applicable, for traumatic brain compression or herniation (S06.A-)

Parent Code Notes: S06

Includes: traumatic brain injury

Excludes1: head injury NOS (S09.90)

Code also: any associated:
open wound of head (S01.-)
skull fracture (S02.-)

Use additional code, if applicable, to identify mild neurocognitive disorders due to known physiological condition (F06.7-)

When To Use S06.313A

The diagnosis describes by the ICD 10 CM S06.313A code refers to contusion and laceration of the right cerebrum, a type of traumatic brain injury caused by a blunt force trauma to the head. This injury can result in significant damage to the brain and cause a wide range of physical and cognitive symptoms.

One of the most common symptoms of this type of injury is unconsciousness, which is often followed by seizures, nausea and vomiting. Increased intracranial pressure, or ICP, is another frequent outcome, leading to a severe headache, temporary or permanent amnesia, physical and mental disability, impaired cognitive function, and difficulty communicating once the patient regains consciousness.

Given the seriousness of this condition, healthcare providers must diagnose it accurately and in a timely manner to ensure proper treatment. Diagnosis typically involves a thorough assessment of the patient’s medical history and symptoms, along with a comprehensive physical examination. Physicians will pay specific attention to the patient’s response to stimuli and pupil dilation, as well as using objective measures like the Glasgow Coma Scale, a standardized tool used to assess the severity of a traumatic brain injury.

In addition to standard diagnostic procedures, healthcare providers may also use imaging techniques such as computed tomography or CT angiography, and magnetic resonance imaging or MR angiography, to identify and monitor any hemorrhage in the brain. They may also use electroencephalography to evaluate the patient’s brain activity and determine the extent of damage.

Once a diagnosis has been made, treatment will depend on the severity of the injury and the associated symptoms. Doctors may prescribe medications such as sedatives, antiseizure drugs, and analgesics to manage any pain, discomfort, or unwanted movements. Additionally, healthcare providers will focus on stabilizing the patient’s airway and circulation, immobilizing the neck or head, and addressing any associated medical issues.

Finally, in severe cases, surgery may be necessary to implant an ICP monitor or evacuate a hematoma, which is a blood clot that forms in the brain after an injury. These procedures aim to relieve pressure and prevent further damage while promoting the patient’s recovery.

In conclusion, the ICD 10 CM S06.313A diagnosis code is a crucial tool used by medical coders and healthcare providers to describe and treat contusion and laceration of the right cerebrum, a serious traumatic brain injury that can have a range of physical and cognitive symptoms. With proper diagnosis and treatment, patients can achieve a successful recovery and resume their normal lives.

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