Subdural Hematoma ICD 10: A Comprehensive Guide

A subdural hematoma represents a serious medical issue characterized by the accumulation of blood between the brain’s surface and the skull. This accumulation, which often arises from head trauma, exerts pressure on the brain; this pressure can result in potentially life-threatening complications. Similarly, the subdural hematoma ICD 10 code is S06.5. This code falls under the category of “Intracranial injury,” specifically referring to subdural hemorrhages.

Subdural hematomas can be categorized as acute, subacute, or chronic, depending on the rate of their development following an injury. Acute cases are particularly severe, necessitating immediate medical attention, which often includes surgical intervention to alleviate pressure on the brain. It remains crucial to stay updated and delve into the more intriguing aspects of this condition. Stay with us until the conclusion of the blog!

What Is a Subdural Hematoma?

A subdural hematoma is a kind of bleeding inside your head. It occurs when blood gathers under the dura mater, one of the layers protecting your brain. It usually happens due to a head injury and can be serious. This bleeding takes place outside the brain and inside the scalp. The ICD 10 for hematoma is I62.9 (Hemorrhage, unspecified).

As blood collects, it increases pressure on the brain and causes various symptoms. If the pressure in the skull rises too high, a subdural hematoma can result in unconsciousness and even death. To get more details about the subdural hematoma and accurate coding process in medical billing practice, contact us at MAVA Care.

Subdural Hematoma ICD Code

The subdural ICD 10 for hematoma is I62.00. The ICD 10 code for subdural hematoma is S06.5X0 which is related to a traumatic subdural hematoma, unspecified.

Other codes for various conditions of this disorder are:

This ICD-10 code I62.00 presents a nontraumatic condition of subdural hematoma.
Subdural hematoma is bleeding between the brain’s dura mater and the arachnoid membrane.
The codes help in correct diagnosis and documentation and proper patient treatment planning.
ICD 10 for hematoma classification also facilitates uniformity in communication among healthcare service providers and insurance companies.
Proper coding is essential for effective and efficient management and tracking of patients.

What Is Unspecified Subdural Hematoma?

Unspecified subdural hematoma refers to a type of bleeding that occurs between the protective layers around the brain. It happens in the subdural space. It arises from ruptured blood vessels, often due to trauma, and leads to blood accumulation. This can create pressure on the brain. The term “unspecified” shows that the hematoma’s exact cause, timing, or characteristics aren’t identified. As the hematoma develops, blood may clot.

Moreover, such complicates the situation further by creating a mass effect. This can lead to neurological deficits or increased intracranial pressure. Symptoms can vary widely; headaches, confusion, seizures, or other cognitive impairments are possible. Prompt medical evaluation is essential because it helps manage the condition. It also minimizes the risk of serious complications.

Unspecified Subdural Hematoma ICD-10

The unspecified ICD 10 for subdural hematoma code is S06.5X0A. This code indicates traumatic subdural hemorrhage without loss of consciousness at an initial encounter. Subdural hematomas are classified under head injuries in the ICD 10 subdural hematoma. However, “unspecified” means there is no specific information about the nature of the bleeding. For example, whether it was chronic or what it was due to was not clearly described. The subcategories may differ because they depend on whether consciousness was lost and how long it was lost if it happened again.

Types of Subdural Hematoma

There are the following types of subdural hematoma include:

1. Acute Subdural Hematoma

This is a complicated type of subdural hematoma. The symptoms are severe, and they are manifested immediately after a head injury. Often, it occurs within minutes to hours. The pressure on your brain increases rapidly because the blood pools. If you do not get diagnosed early enough, you may lose consciousness or have paralysis. But this can lead to death.

2.Acute Subdural Hematoma ICD 10 Code

The ICD 10 for hematoma code for an acute subdural is S06.5X0A. It changes to S06.5X7A if there is a loss of consciousness for an unspecified duration during the initial encounter. Acute subdural hematomas happen when blood accumulates quickly between the brain’s surface and the dura mater.

Accurate coding helps clinicians manage treatment effectively. However, it also documents the severity of the situation and tracks patient outcomes over time. This is crucial because it impacts care decisions.

3. Subacute Subdural Hematoma

A subacute subdural hematoma is a type of bleeding that happens between the brain and its outer covering. It usually follows a head injury. Symptoms may not appear immediately; however, they can develop over hours to days or weeks after the initial trauma. This delayed onset can lead to misdiagnosis. Sometimes, doctors underestimate the injury’s severity, which can be dangerous. Thus, it is common awareness of these symptoms is crucial because timely treatment is essential.

Subacute Hematoma ICD 10 Code

The subdural hematoma ICD 10 for a subacute subdural hematoma is S06.5X2. Here’s the breakdown:

S06: Intracranial injury
5X: Subdural hematoma
2: Specifies a subacute (or non-acute) traumatic hematoma
Use an additional character if needed to indicate the encounter type.

4. Chronic Subdural Hematoma

Such issues occur commonly in people older than 65. Bleeding takes place slowly, and there may be no sign at all until weeks or even months after the trauma occurred. You may not even recall how your head injury occurred because of the delay that occurs before symptoms manifest.

Chronic Subdural Hematoma ICD 10 Code

The subdural hematoma ICD 10 for chronic condition is listed as I62.03, indicating it is a chronic subdural hematoma, commonly due to minor head injuries or age-related brain-structure changes in elderly populations. Coding for such purposes ensures proper documentation and records for chronic care and constant monitoring.

Is Subdural Hematoma the same as Subdural Hemorrhage?

Subdural Hematoma and Subdural Hemorrhage are related but not identical terms; a subdural hematoma specifically refers to a collection of blood that forms between the dura mater and the brain due to trauma, while subdural hemorrhage is a broader term that encompasses any bleeding in that same space, including the initial bleeding event that may lead to a hematoma.

Essentially, all subdural hematomas are a type of subdural hemorrhage, but not all subdural hemorrhages result in a hematoma. To avail of our accurate medical coding and billing services, simply give us a call or email us at: info@mavacare.com.

Can You fully Recover from a Subdural Hematoma?

Yes, most patients can easily recover from subdural hematoma, especially if there is an early diagnosis. The degree of recovery greatly depends on various factors, including the hematoma’s size and area. A patient’s general condition and age also contribute to this. The treatment course may be a monitoring schedule, medications, or the surgical removal of the hematoma, thereby relieving pressure on the brain tissue and thus helping to produce a better outcome.

However, the recovery is not uniform. Some patients may have to live with long-term problems, which include cognitive changes, physical impairments, or psychosocial difficulties. Therefore, continued follow-up care is necessary to identify complications that may arise along the way.

Specific Codes for Subdural Hematoma

1. ICD Code For 2 Hours Lost Subdural Hematoma

S06.5X0A is a non-traumatic subdural hematoma, which is an intracerebral hemorrhage with loss of consciousness of unspecified duration. If the exact duration of lost consciousness is 2 hours, you may have to report it using proper external cause or status codes according to clinical documentation.

2. Non-Traumatic Subdural Hematoma ICD-10

I62.00: Non-traumatic subdural hematoma, unspecified.
I62.01: Non-traumatic subdural hematoma, right side.
I62.02: Non-traumatic subdural hematoma, left side.
I62.09: Non-traumatic subdural hematoma, other specified side.

3. Traumatic Subdural Hematoma ICD-10

S06.5X0: Traumatic subdural hematoma, unspecified.
S06.5X1: Traumatic subdural hematoma, right side.
S06.5X2: Traumatic subdural hematoma, left side.
S06.5X3: Traumatic subdural hematoma, bilateral.
S06.5X9: Traumatic subdural hematoma, unspecified side.

Treatment For Subdural Hematoma

Most commonly, surgical intervention is needed for subdural hematomas as soon as possible. Here are the three commonly used surgical methods for subdural hematomas:

Burr Hole Trephination:

a hole is drilled in the skull. This is done over the area of the subdural hematoma. Blood is suctioned out through the hole; however, the procedure must be done carefully. Although it sounds simple, it requires precision. The goal is to relieve pressure and restore normal function. There are risks because any mistake could lead to complications

Craniotomy:

A larger section of the skull is removed to allow better access to the subdural hematoma. This reduces pressure. However, the removed skull is replaced shortly after the procedure, although it can take time. The operation is necessary because it helps relieve symptoms.

Craniectomy:

The skull is partially removed to allow the injured brain to expand and swell without suffering permanent damage. Craniectomy is rarely performed on patients with subdural hematoma. Though usually lifesaving, decompressive surgeries are not free from complications. Some possible complications include blood clots, water on the brain or hydrocephalus, and an increased risk of cranial bleeding.

In a Nutshell

Subdural hematoma ICD 10 refers specifically to subdural hemorrhages as part of intracranial injuries. Subdural hematomas have different death rates depending on their type. Acute subdural hematoma is often the most dangerous one, with a death rate of about 66%. One study showed that, after one year, the death rate for chronic subdural hematoma was as high as 32%. You’ll learn about the codes and detailed information in the above section. However, if you are a healthcare provider who wants error-free coding and smooth billing for your practice, reach out to MAVA Care medical billing company. We are here to assist you in handling all your billing processes and fix the issues related to your practice.