ICD-10 Coding and Documentation for Subdural Hematoma

1. (800) 670 2809 ICD-10 Coding and Documentation for Subdural Hematoma

2. 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.

3. 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

4. Timely treatment helps to minimize the risk of severe complications and even death. After the initial testing, diagnostic tests like computed tomography (CT) or magnetic resonance imaging (MRI) scans will be conducted to get a clear picture of the different parts of the brain and to check for any specific signs of blood clotting.

5. 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

6. 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

7. 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.

8. Contact us: Headquarters:8596 E. 101st Street, Suite HTulsa, OK 74133 Phone : (800) 670 2809 E-mail : info@managedoutsource.com THANK YOU…