Injury to brachial plexus due to birth trauma

This code signifies damage to the brachial plexus nerves in a neonate, specifically caused by mechanical forces during the birth process. This injury can result in varying degrees of weakness or paralysis in the affected arm and hand, ranging from Erb's palsy to Klumpke's palsy. The trauma typically involves stretching or tearing of the nerve roots as the infant passes through the birth canal.

Apply this code when documentation clearly indicates a diagnosis of brachial plexus injury in a newborn, with a direct causal link to the birthing event. This includes cases where excessive traction on the infant's head or shoulder during delivery is noted. Supporting documentation would include physician notes detailing the injury, its onset at birth, and the specific mechanism of trauma if identified.

• Ensure the documentation explicitly states "birth trauma" as the etiology; otherwise, consider codes for other causes of brachial plexus injury.
• Do not confuse this with congenital anomalies of the brachial plexus, which have a different etiology and coding.
• Always sequence this code as a primary diagnosis when it is the reason for the encounter, followed by any manifestations or specific types of palsy (e.g., Erb's palsy).