ICD-10 Coding and Documentation for Subdural Hematoma

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ICD-10 Coding and Documentation for Subdural
Hematoma
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Subdural hematoma is a type of internal bleeding
in the skull. Also referred to as subdural
hemorrhage, the condition occurs when a vein
located below the skull ruptures and starts to
bleed. It can be caused by minor accidents to the
head, major trauma, or the spontaneous bursting
of a blood vessel in the brain (aneurysm).
Depending on the type and severity of the injury,
surgery can be recommended for subdural hematoma.
The most dangerous type, acute subdural hematoma
is usually caused by a vehicle accident or a blow
to the head. Chronic subdural hematoma is caused
by mild or repeated head injuries. Neurosurgeons
or neurology specialists providing treatment for
this type of injuries should ensure that claims
are submitted with the correct medical codes.
Professional medical coding companies can help
ensure accurate documentation and reimbursement.
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Common Symptoms and Diagnosis

• Symptoms of this condition depend on the type of
  injury and can vary from one person to another.
  Common symptoms include
• Severe headache
• Vision problems
• Slurred speech
• Seizures
• Mood swings
• Loss of consciousness or
• passing out
• Dizziness and vomiting
• Confusion
• Apathy and weakness

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Documenting Subdural Hematoma with ICD-10 Codes

• Neurosurgery medical coding involves using the
  specific ICD-10 diagnosis codes for reporting on
  the medical claims they submit to health insurers
  for reimbursement. The ICD-10 codes for Subdural
  Hemorrhage include
• S06.5 Traumatic subdural hemorrhage
• S06.5X Traumatic subdural hemorrhage
• S06.5X0 Traumatic subdural hemorrhage without
  loss of consciousness

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• S06.5X1 Traumatic subdural hemorrhage with loss
  of consciousness of 30 minutes
  or less
• S06.5X2 Traumatic subdural hemorrhage with loss
  of consciousness of 31 minutes to 59 minutes
• S06.5X3 Traumatic subdural hemorrhage with loss
  of consciousness of 1 hour to 5 hours 59 minutes
• S06.5X4 Traumatic subdural hemorrhage with loss
  of consciousness of 6 hours to 24 hours
• S06.5X5 Traumatic subdural hemorrhage with loss
  of consciousness greater than 24 hours with
  return to pre-existing conscious level

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Even after treatment, many patients may be left
with some long-lasting problems such as mood
swings, memory/concentration problems, seizures,
speech problems and weakness in limbs. There are
even chances that the symptoms may come back and
surgery may need to be repeated.
Physicians treating such complex conditions can
consider outsourcing medical coding to a reliable
medical billing and coding outsourcing company,
to ensure correct and timely medical billing and
claims submission.
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