ICD-10 Coding for Acute Subdural Hematoma(S06.5X1A, I62.01)
Complete ICD-10-CM coding and documentation guide for Acute Subdural Hematoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Acute Subdural Hematoma
S06.5XPrimary Range
Traumatic subdural hemorrhage
This range includes codes for traumatic subdural hemorrhage, differentiated by the duration of loss of consciousness and encounter type.
Nontraumatic acute subdural hemorrhage
This code is used for nontraumatic acute subdural hemorrhage, often related to anticoagulant use or vascular abnormalities.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S06.5X1A | Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter | Use for initial encounters of traumatic subdural hemorrhage with brief loss of consciousness. |
|
| I62.01 | Nontraumatic subdural hemorrhage | Use when the subdural hemorrhage is nontraumatic. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for acute subdural hematoma
Essential facts and insights about Acute Subdural Hematoma
Primary ICD-10-CM Codes for acute subdural hematoma
Decision Criteria
clinical Criteria
- Head trauma with brief LOC and CT confirmation
Applicable To
- Acute traumatic subdural hematoma with brief LOC
Excludes
- Nontraumatic subdural hemorrhage (I62.01)
Clinical Validation Requirements
- Documented head trauma
- Loss of consciousness ≤30 minutes
- CT scan showing hyperdense subdural collection
Code-Specific Risks
- Incorrectly coding as nontraumatic when trauma is documented
Coding Notes
- Ensure documentation specifies the traumatic nature and duration of LOC.
I62.01 - Nontraumatic subdural hemorrhage
Use when the subdural hemorrhage is nontraumatic.
Applicable To
- Spontaneous subdural hematoma
Excludes
- Traumatic subdural hemorrhage (S06.5X-)
Clinical Validation Requirements
- No history of trauma
- Possible anticoagulant use or vascular abnormality
- CT or MRI confirming hemorrhage
Coding Notes
Ensure the absence of trauma is clearly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Long term (current) use of anticoagulants
Z79.01Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Acute Subdural Hematoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S06.5X1A.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding guidelines., Financial: Potential for claim denials.
Mitigation Strategy
Always document LOC duration in the patient's record.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: May result in non-compliance with coding standards., Data Quality: Affects the accuracy of patient records.
Mitigation Strategy
Verify the presence or absence of trauma in the patient's history.
Impact
Failure to document trauma can lead to incorrect coding.
Mitigation Strategy
Implement a checklist for trauma documentation in patient records.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Acute Subdural Hematoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Acute Subdural Hematoma
Use these documentation templates to ensure complete and accurate documentation for Acute Subdural Hematoma. These templates include all required elements for proper coding and billing.
Initial encounter for traumatic acute subdural hematoma
Specialty: Emergency MedicineRequired Elements
- Mechanism of injury
- Duration of loss of consciousness
- CT findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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