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2025 ICD-10-CM code S00.0

Superficial injury of the scalp.

Use additional codes to identify any retained foreign body, associated infection, and the external cause of injury (Chapter 20).

Modifiers may be applicable depending on the circumstances of the encounter and the services provided.

Medical necessity is established by the presence of a superficial scalp wound requiring treatment to prevent infection, manage pain, and promote healing.

Providers diagnose the condition based on the patient's history and physical examination. Treatment options include analgesics for pain, wound dressing and cleaning to prevent infection, adhesive strips to close the wound, antibiotics, or minor surgical repair if needed.

IMPORTANT:Use additional code to identify any retained foreign body (Z18.-).Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate the cause of injury. Codes within the T section that include the external cause do not require an additional external cause code.

In simple words: A minor scrape or cut on the scalp with little or no bleeding or swelling. This can happen from a fall, accident, or surgery.It might be painful, swollen, red, or tender. Treatment may include pain relievers, cleaning the wound to prevent infection, and possibly stitches or antibiotics.

A superficial injury of the scalp involves a minimal scrape or wound with minimal bleeding, if any, or swelling of the affected area.This type of injury may result from a fall, accident, or surgery.The injury may cause pain, swelling, bleeding, redness, warmth, and tenderness in the affected area. Treatment may include analgesics for pain relief, wound dressing and cleaning to prevent infection, adhesive strips to close the wound, antibiotics to prevent infection, or minor surgical repair if needed.

Example 1: A patient falls and scrapes their scalp during a sporting event. The wound is superficial with minimal bleeding. , A patient undergoes scalp surgery, resulting in a minor superficial wound. , A child experiences a minor scalp laceration from a fall at home, exhibiting only minimal bleeding and swelling.

Patient history detailing the mechanism of injury, physical examination findings documenting the location, size, and depth of the wound, and any treatment provided (e.g., wound cleaning, closure, medication administration).

** This code is for superficial scalp injuries only and excludes more serious injuries like skull fractures, brain injuries, or deep wounds.Always code to the highest level of specificity.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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