Skip to content

To Code or Not to Code Brain Compression?

Coding or not coding Brain compression (G93.5) caused by trauma is a topic of frequent discussion and confusion. Coding Clinic, Second Quarter 2020 page 31, answers a question about brain compression in trauma but does not lessen the confusion. The source of confusion is anatomy and injury location. Definitions and increased clinical understanding may help relieve the confusion and provide insight into proper code assignment.

A way to define masses, bleeding, and injury in and around the brain is to describe them as EXTRA- AXIAL and INTRA -AXIAL.  The term AXIAL relates to the brain. EXTRA-AXIAL means around the brain. In turn, INTRA -AXIAL refers to in the brain. For example, subdural and epidural hemorrhages are EXTRA-AXIAL. A hemorrhage into the left cerebral cortex following a thrombotic stroke is INTRA–AXIAL.

In older adults, especially on anticoagulants, a minor bump to the head can result in a TRAUMATIC Subdural hemorrhage. As the subdural hemorrhage that is located on the surface of the brain gets larger the brain becomes compressed. This compression is evident when the individual exhibits diminished alertness, focal neurological signs like weakness, marked hypertension, and possibly vomiting. On CT or MRI imaging the findings are the subdural hemorrhage and compression of the brain under the hemorrhage. The brain tissue is compressed but it has not been injured by the trauma. The EXTRA AXIAL lesions are not brain injuries. SUBDURAL and EPIDURAL Hemorrhage and traumatic subarachnoid hemorrhage may have associated brain compression.  The CT and MRI imaging descriptions of brain compression may use terms like, midline shift, compression or effacement of the ventricles.  In the circumstances where the condition of brain compression requires extra monitoring, treatment, or extra utilization of resources it should be coded but only when an EXTRA-AXIAL injury is present.

Head injury that results from significant trauma may have associated brain injury. The traumatic injuries to the brain are described as: traumatic diffuse cerebral edema, diffuse and focal traumatic brain injury, contusion and laceration of the brain, traumatic hemorrhage of the brain. These are serious injuries to the brain tissue. These injuries can be complex and involve more than one area of the brain with more than one type of injury. In this type of brain injury, brain compression, G93.5, is not coded.

When considering the reporting of brain compression, G93.5, in trauma cases, first determine is the injury EXTRA AXIAL or INTRA AXIAL. If the injury is EXTRA AXIAL determine if there is any associated INTRA AXIAL injury. If the injury is only EXTRA-AXIAL and brain compression is present and required monitoring, treatment, or extra resources, code G93.5, brain compression.  Remember, the radiology reports describing the CT and MRI images of the brain are a critical source of information. These reports usually describe in detail the location and extent of the injury, EXTRA -AXIAL and/or INTRA -AXIAL. When a query is needed it is recommended that you refer to these reports.


Back to All Blog Posts

Sign Up For Updates From Enjoin