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2025 ICD-10-CM code S00

Superficial injury of the head.

Code also for any associated infection.Use additional code(s) from Chapter 20 to specify the cause of injury unless already included in the code.

Modifiers may be applicable depending on the circumstances of the encounter and the services provided.Consult the official coding guidelines for details.

Medical necessity is established by the presence of a superficial injury to the head requiring medical attention for diagnosis, treatment, or prevention of complications (e.g., infection).

Providers diagnose superficial head injuries based on patient history and physical examination. Treatment may involve pain management (analgesics), wound care (cleaning, dressing), closure (adhesive strips), infection prevention (antibiotics), and/or minor surgical repair.

IMPORTANT:Use additional code to identify any retained foreign body (Z18.-).Secondary codes from Chapter 20 (External causes of morbidity) should be used to indicate the cause of injury, unless the T-section code already includes the external cause.

In simple words: This code describes a minor scrape or wound on the head, possibly with some swelling, caused by an accident or injury.It's a superficial injury, meaning it's only on the surface of the skin. Treatment might include cleaning the wound, pain relievers, and possibly stitches.

A superficial injury of the head involves a minimal scrape or wound with minimal bleeding, if any, or swelling of the affected area due to a fall, accident, or surgery.The injury may result in pain, swelling, bleeding, redness, warmth, and tenderness. Diagnosis is based on the patient's history and physical examination. Treatment may include analgesics for pain, wound dressing and cleaning to prevent infection and stop bleeding, adhesive strips to close the wound, antibiotics to prevent infection, or minor surgical repair if needed.

Example 1: A patient falls and sustains a small abrasion on their forehead with minimal bleeding. , A child scrapes their scalp during playtime, resulting in a superficial wound with slight swelling., A patient undergoes a minor surgical procedure on their head, leaving a superficial wound requiring sutures and antibiotic treatment.

Patient history detailing the mechanism of injury, physical examination findings (location, size, depth of wound, presence of bleeding or swelling), description of any treatment provided (e.g., wound cleaning, closure method, medications administered), and any follow-up plans.

** Excludes: birth trauma (P10-P15), obstetric trauma (O70-O71), burns and corrosions (T20-T32), effects of foreign body in specific locations, frostbite (T33-T34), insect bites/stings (T63.4), diffuse/focal cerebral contusion (S06.2-, S06.3-), injury of eye and orbit (S05.-), open wound of head (S01.-).

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