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2025 ICD-10-CM code S00.93XA

Contusion of unspecified part of head, initial encounter.

Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Use additional code to identify any retained foreign body, if applicable (Z18.-)

The medical necessity for this code is established by the presence of a contusion on the head due to an external cause, such as a fall or trauma.

Contusion of the lip may result in redness, swelling, tenderness, pain, and skin discoloration. Providers diagnose the condition on the basis of patient’s history of recent injury and physical examination. Treatment options include application of ice over the affected area to reduce swelling and administration of analgesics to reduce pain.

In simple words: A bruise on an unspecified part of the head, seen for the first time.

Contusion, also known as a bruise or ecchymosis, of an unspecified part of the head refers to discoloration due to a blunt injury that breaks the small blood vessels but not the skin and results in subcutaneous accumulation of blood. The provider does not document the part of the head at this initial encounter for the contusion.

Example 1: A patient presents to the emergency room after falling and hitting their head. The physician notes a contusion on the head, but the specific location is not documented in the initial encounter., A child falls off their bike and sustains a head injury. On examination, a contusion is noted, but further details about the location are not yet available., A patient is involved in a motor vehicle accident and presents with a head contusion. Initial imaging is ordered, but the precise location of the injury is not yet determined.

Documentation should include evidence of a blunt injury to the head resulting in a contusion. The documentation should also clearly state that the specific location of the contusion on the head is unspecified at the initial encounter.If the location is specified, a more specific code should be used.

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