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2025 ICD-10-CM code P52.6

Cerebellar (nontraumatic) and posterior fossa hemorrhage of newborn. This condition involves bleeding in the cerebellum and posterior fossa of the brain, not caused by trauma, specifically occurring in newborns.

This code should be used only for newborn records (up to 28 days after birth) and not on maternal records. It is important to differentiate it from hemorrhages due to birth trauma (P10.-) or other injury (S06.-), which have separate codes.

The medical necessity relates to the need to identify and manage the intracranial hemorrhage in the newborn. This involves determining the cause, assessing the severity, and implementing appropriate treatment strategies to minimize potential long-term neurological damage.

The clinical responsibility for this code lies with the neonatologist, pediatrician, or other healthcare provider responsible for the newborn's care. Diagnosing P52.6 involves assessing symptoms, performing imaging studies (such as cranial ultrasound or MRI), and potentially consulting with specialists like neurologists.Treatment involves managing the bleeding and any related complications, such as increased intracranial pressure.

In simple words: A newborn baby has bleeding in the back part of their brain called the cerebellum and posterior fossa, not due to physical trauma.

Cerebellar (nontraumatic) and posterior fossa hemorrhage of newborn.This diagnosis represents bleeding within the cerebellum and/or the posterior fossa (the area at the base of the skull that contains the cerebellum and brainstem) in a newborn infant.The hemorrhage is specified as nontraumatic, meaning it's not caused by physical injury like birth trauma.

Example 1: A newborn infant exhibits signs of neurological distress, including lethargy, poor feeding, and irregular breathing. Imaging reveals a cerebellar hemorrhage, which is determined to be nontraumatic. The diagnosis is P52.6., A premature infant develops difficulty regulating their body temperature and heart rate.A cranial ultrasound shows a posterior fossa hemorrhage not associated with any known trauma. The infant is diagnosed with P52.6., During a routine newborn examination, a physician notices abnormal eye movements and muscle tone. Further investigation through a head MRI confirms a nontraumatic hemorrhage in the cerebellum, leading to a P52.6 diagnosis.

Documentation should include the evidence of hemorrhage (from imaging studies), details about the location (cerebellum, posterior fossa), confirmation that the bleed is nontraumatic, and the newborn's presenting symptoms.Any associated conditions or complications should also be documented.

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