Shaken infant syndrome, initial encounter

This code signifies the diagnosis of Shaken Baby Syndrome (SBS), a severe form of abusive head trauma in infants and young children. It results from violent shaking, leading to brain injury, retinal hemorrhages, and often other injuries like fractures, without external signs of trauma.

Apply this code when a definitive diagnosis of Shaken Infant Syndrome is made during the initial presentation for treatment. This includes cases where the infant is admitted for evaluation and management of the injuries sustained from the shaking.

• Always assign an external cause code (V00-Y99) to indicate the circumstances of the injury.
• Code all associated injuries, such as intracranial hemorrhage, retinal hemorrhage, and fractures, in addition to this code.
• Ensure the "A" seventh character is used only for the initial encounter for treatment of the condition.