AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2024 Issue 2; Ask the Editor

Traumatic Pneumocephalus with Subdural Hematoma and Skull Fractures

A patient was admitted following an all-terrain vehicle accident without loss of consciousness. Documentation states traumatic pneumocephalus, left subdural hematoma (SDH), bilateral temporal bone fractures with associated fluid in the bilateral mastoid air cells, sphenoid sinus, and maxillary sinus. Injury codes were assigned for the SDH (S06.5-) and temporal bone fractures (S02.19-). Traumatic pneumocephalus is not specifically classified in ICD-10-CM. Pneumocephalus is indexed to code G93.89, Other specified disorders of brain. However, this code alone does not appear to capture that the pneumocephalus was traumatic. Since pneumocephalus is also known as an intracranial aerocele, would it be appropriate to assign code T79.0XXA, Air embolism (traumatic), initial encounter, or code T79.8XXA, Other early complications of trauma, initial encounter, as an additional code to specifically capture traumatic pneumocephalus? What is/are the correct code(s) for traumatic pneumocephalus? ...

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