AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 1; Ask the Editor

Sunken Flap Syndrome

A patient with a history of traumatic brain injury, status post bilateral craniectomies is admitted for skull reconstruction due to bilateral frontoparietal cranial defects. Cranioplasty was performed on the right side, however during the recovery phase the patient became obtunded, encephalopathic and bradycardic. The physician noted the previous left-sided skull flap appeared sunken, consistent with sunken flap syndrome and paradoxical brain shift, which required left-sided reconstruction. What are the correct code assignments for sunken flap syndrome? ...

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