2025 ICD-10-CM code S06.5
(Active) Effective Date: N/A Revision Date: N/A Injury - Injuries to the head (S00-S09) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Traumatic subdural hemorrhage resulting from traumatic brain injury.
Modifiers may be applicable based on the specific circumstances of the encounter (e.g., place of service, type of anesthesia, etc.)
Medical necessity for treatment of traumatic subdural hematoma is established by the presence of symptoms and confirmed by imaging studies demonstrating a significant intracranial hemorrhage.The severity of the hematoma, neurological status, and potential for neurological deterioration dictate the urgency of intervention.Surgical intervention is indicated for symptomatic subdural hematomas that compromise neurological function or show signs of expansion.
Diagnosis and treatment of traumatic subdural hemorrhage involves a multidisciplinary approach including neurologists, neurosurgeons, and other healthcare professionals. Responsibilities encompass taking detailed patient history, conducting a thorough neurological examination, ordering and interpreting diagnostic imaging (CT, MRI), implementing appropriate medical management (medication, airway management), performing surgical intervention if necessary (hematoma evacuation, ICP monitoring), and providing post-operative care and rehabilitation.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: Traumatic subdural hemorrhage is bleeding inside the head, under a protective layer covering the brain, caused by a head injury like a fall or car accident.This can lead to unconsciousness, seizures, vomiting, headaches, memory problems, and other difficulties. Doctors use scans to diagnose it and may treat it with medication or surgery.
Traumatic subdural hemorrhage is bleeding beneath the dura mater (outer membrane covering the brain and spinal cord) caused by traumatic brain injury, such as blunt trauma (e.g., fall, assault) or deceleration injury (e.g., motor vehicle collision).It often presents with unconsciousness, seizures, nausea, vomiting, increased intracranial pressure (ICP), headache, amnesia (temporary or permanent), physical and mental disability, cognitive impairment, and communication difficulties. Diagnosis involves patient history, physical examination (including Glasgow Coma Scale and pupil response), and imaging (CT angiography, MR angiography). Treatment may include medication (sedatives, corticosteroids, antiseizure drugs, analgesics), airway and circulatory stabilization, cervical immobilization, management of associated problems, and surgery (ICP monitoring, hematoma evacuation).
Example 1: A 25-year-old male sustains a traumatic brain injury in a motorcycle accident. He loses consciousness briefly at the scene, then becomes increasingly drowsy and confused. CT scan reveals a subdural hematoma requiring emergency neurosurgical evacuation., A 70-year-old female falls at home and hits her head.She experiences worsening headaches, nausea, and confusion over the following days.She is admitted to the hospital, and MRI shows a chronic subdural hematoma requiring surgical intervention., A 10-year-old child suffers a subdural hematoma secondary to an assault. He arrives at the hospital unconscious with a depressed skull fracture.A craniotomy is required to evacuate the hematoma and repair the skull fracture.
Detailed patient history including mechanism of injury (MOI), loss of consciousness, neurological examination findings (Glasgow Coma Scale, pupil reactivity), imaging studies (CT scan or MRI), surgical reports (if applicable), and detailed progress notes documenting the patient's course of treatment and recovery.
** Accurate coding requires a thorough understanding of the patient's clinical presentation, diagnostic findings, and treatment received.Always refer to the most up-to-date coding guidelines and payer-specific policies for reimbursement.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier may apply if the service is broken down into professional and technical components.Consult your payer's guidelines for specificity.
- Fee Schedule: Refer to CMS or payer-specific fee schedules for historical reimbursement rates.These rates are subject to change.
- Specialties:Neurosurgery, Neurology, Emergency Medicine
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center