ICD-10 Coding for Epidural Hemorrhage(S06.4X-, G95.19, T81.89-)
Complete ICD-10-CM coding and documentation guide for Epidural Hemorrhage. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Epidural Hemorrhage
S06.4Primary Range
Intracranial injury with epidural hemorrhage
Used for traumatic intracranial epidural hemorrhages.
Other complications of procedures, not elsewhere classified
Used for post-procedural spinal epidural hematomas.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S06.4X- | Traumatic epidural hemorrhage | Use for traumatic intracranial epidural hemorrhages. |
|
| G95.19 | Other vascular myelopathies | Use for non-traumatic spinal epidural hematomas. |
|
| T81.89- | Other complications of procedures, not elsewhere classified | Use for hematomas following surgical procedures. |
|
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 epidural hemorrhage
Essential facts and insights about Epidural Hemorrhage
Primary ICD-10-CM Codes for epidural hemorrhage
Decision Criteria
clinical Criteria
- Presence of trauma and intracranial hemorrhage
Applicable To
- Traumatic intracranial epidural hemorrhage
Excludes
- Spinal epidural hemorrhage
Clinical Validation Requirements
- CT/MRI showing intracranial epidural blood
- Documented trauma mechanism
Code-Specific Risks
- Incorrectly coding spinal hemorrhages as intracranial
Coding Notes
- Ensure documentation specifies the duration of loss of consciousness.
G95.19 - Other vascular myelopathies
Use for non-traumatic spinal epidural hematomas.
Applicable To
- Non-traumatic spinal epidural hematoma
Excludes
- Traumatic spinal cord injury
Clinical Validation Requirements
- MRI showing spinal epidural hematoma
- Absence of trauma or procedure
Coding Notes
Document specific spinal levels involved.
T81.89- - Other complications of procedures, not elsewhere classified
Use for hematomas following surgical procedures.
Applicable To
- Post-procedural spinal epidural hematoma
Excludes
- Non-procedural hematomas
Clinical Validation Requirements
- Documentation of recent procedure
- Imaging showing hematoma
Coding Notes
Ensure linkage to the procedure performed.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Epidural Hemorrhage to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S06.4X-.
Impact
Clinical: Incomplete encounter information., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always include encounter type character., Review coding guidelines.
Impact
Reimbursement: Incorrect reimbursement for spinal cases., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate data on hemorrhage location.
Mitigation Strategy
Use G95.19 for non-traumatic spinal cases.
Impact
Using intracranial codes for spinal hemorrhages.
Mitigation Strategy
Educate coders on proper code selection.
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 Epidural Hemorrhage, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Epidural Hemorrhage
Use these documentation templates to ensure complete and accurate documentation for Epidural Hemorrhage. These templates include all required elements for proper coding and billing.
Non-traumatic spinal epidural hematoma
Specialty: NeurologyRequired Elements
- MRI findings
- Neurological deficits
- Absence of trauma
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Epidural Hemorrhage? Ask your questions below.