ICD-10 Coding for Traumatic Intracerebral Hemorrhage(S06.35XA, S06.36XA)
Complete ICD-10-CM coding and documentation guide for Traumatic Intracerebral Hemorrhage. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Traumatic Intracerebral Hemorrhage
S06.-Primary Range
Intracranial injury, including concussion, contusion, laceration, and hemorrhage
This range includes all traumatic intracranial injuries, including traumatic intracerebral hemorrhage.
Cerebrovascular diseases
This range is for nontraumatic cerebrovascular events and is excluded for traumatic cases.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S06.35XA | Traumatic hemorrhage of left cerebrum with loss of consciousness of 30 minutes or less, initial encounter | Use when there is a documented traumatic hemorrhage in the left cerebrum with specified LOC duration. |
|
| S06.36XA | Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter | Use when there is a documented traumatic hemorrhage in the right cerebrum with specified LOC duration. |
|
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 traumatic intracerebral hemorrhage
Essential facts and insights about Traumatic Intracerebral Hemorrhage
Primary ICD-10-CM Codes for traumatic intracerebral hemorrhage
Decision Criteria
clinical Criteria
- Presence of traumatic event leading to hemorrhage
documentation Criteria
- Detailed LOC duration and imaging findings
Applicable To
- Traumatic hemorrhage of left cerebrum with brief LOC
Excludes
- Nontraumatic intracerebral hemorrhage (I61.-)
Clinical Validation Requirements
- CT/MRI showing hemorrhage in the left cerebrum
- Documented LOC duration
Code-Specific Risks
- Incorrectly coding as nontraumatic hemorrhage
Coding Notes
- Ensure documentation specifies trauma as the cause of hemorrhage.
S06.36XA - Traumatic hemorrhage of right cerebrum with loss of consciousness of 31 minutes to 59 minutes, initial encounter
Use when there is a documented traumatic hemorrhage in the right cerebrum with specified LOC duration.
Applicable To
- Traumatic hemorrhage of right cerebrum with moderate LOC
Excludes
- Nontraumatic intracerebral hemorrhage (I61.-)
Clinical Validation Requirements
- CT/MRI showing hemorrhage in the right cerebrum
- Documented LOC duration
Coding Notes
Ensure documentation specifies trauma as the cause of hemorrhage.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Anticoagulant therapy causing coagulopathy
D68.62Differential 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 Traumatic Intracerebral Hemorrhage to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S06.35XA.
Impact
Clinical: Affects treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Use structured templates, Verify imaging reports for laterality
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Ensure documentation specifies the traumatic nature of the hemorrhage.
Impact
Failure to sequence TICH as the principal diagnosis when appropriate.
Mitigation Strategy
Educate coders on sequencing rules and use of external cause codes.
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 Traumatic Intracerebral Hemorrhage, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Traumatic Intracerebral Hemorrhage
Use these documentation templates to ensure complete and accurate documentation for Traumatic Intracerebral Hemorrhage. These templates include all required elements for proper coding and billing.
Emergency Department Admission
Specialty: Emergency MedicineRequired Elements
- Mechanism of injury
- LOC duration
- Imaging findings
- Anticoagulation status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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