2025 ICD-10-CM code S09
This code describes an unspecified injury to the head where the specific nature of the injury is not documented.
Modifiers are typically not applicable to ICD-10-CM codes.
Medical necessity depends on the severity of the signs, symptoms, and the clinical picture of the patient.
Providers diagnose head injuries based on patient history, physical examination (checking for fractures and nerve or blood vessel damage), imaging techniques (X-rays, CT scan, MRI, PET, ultrasound, EEG), and laboratory tests. Treatment includes stopping bleeding, cleaning wounds, applying dressings, medications (analgesics, antibiotics, antiepileptics, diuretics, tetanus prophylaxis), and potentially surgery.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: This code is used when someone has hurt their head, but the doctor hasn't specified exactly what kind of injury it is, like a cut or a broken bone.
Other and unspecified injuries of head not covered by other codes refer to an insult or trauma to the structures of the head such as the scalp, brain, or skull that may occur due to traumatic and nontraumatic conditions. The provider does not document the nature of the injury.
Example 1: A patient presents to the ER after a fall, complaining of head pain. The physician documents "head injury" but does not specify the type of injury. Code S09 is used., A patient with altered mental status is brought in by ambulance. There is no clear history available, and initial imaging does not reveal specific intracranial injuries. Code S09 is used until further diagnostic information is available. , A patient reports hitting their head on a low-hanging beam.There is a bump but no other visible injuries, and neurological exam is normal. The physician documents "head injury, unspecified." Code S09 is applied.
Documentation should include the details of the event causing the injury, the patient's symptoms, and any diagnostic findings or treatments provided. Even if the specific injury type is unknown, document all available information.
** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). Excludes2: burns and corrosions (T20-T32), effects of foreign body in ear (T16), effects of foreign body in larynx (T17.3), effects of foreign body in mouth NOS (T18.0), effects of foreign body in nose (T17.0-T17.1), effects of foreign body in pharynx (T17.2), effects of foreign body on external eye (T15.-), frostbite (T33-T34), insect bite or sting, venomous (T63.4).Always query the physician for more specific information when the documentation is unclear.
- Specialties:Emergency Medicine, General Surgery, Neurology, Neurosurgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Office, Urgent Care Facility, Outpatient Hospital, Home, Other Place of Service