Sternomastoid injury due to birth injury

This code signifies damage to the sternocleidomastoid muscle in a newborn, specifically resulting from trauma during the birth process. This injury often presents as a palpable mass or swelling within the muscle, leading to torticollis or head tilt.

Apply this code when documentation clearly indicates a sternocleidomastoid injury directly attributable to birth trauma. This includes cases of congenital muscular torticollis where the etiology is explicitly linked to birth-related events, such as difficult deliveries or use of assistive devices.

• Ensure the medical record explicitly states "birth injury" as the cause of the sternocleidomastoid damage.
• Do not use for torticollis of unknown or non-birth-related etiology; other codes for congenital torticollis (e.g., Q68.0) would be more appropriate.
• Consider co-reporting with codes for other birth injuries if present, following sequencing guidelines.