Traumatic Epidural and Subdural Hematomas

Becky Buegel, RHIA, CDIP, CHP Medical Coding Leave a Comment

Traumatic Epidural and Subdural Hematomas

Chuck B. sustained a comminuted linear skull fracture due to an auto accident. First seen in the ED he was subsequently admitted to the hospital for observation. Several days post-discharge he was back in the ED complaining of visual difficulties and a severe R-sided headache. CT scan showed an epidural hematoma. A sliver of the skull fracture had pierced the meningeal artery. The patient was immediately transferred to a Level 1 trauma center where he underwent an emergency craniotomy for removal of the hematoma.

While new and experienced coders know medical terminology, it never hurts to review terms like hematoma, epidural, and subdural. The term hematoma literally means “blood tumor”. A more easily understood (especially for a lay person) definition would be a mass of clotted blood that forms in a tissue, organ, or body space, usually from a damaged artery. An epidural hematoma (EDH) is a collection of blood that forms between the skull and the dura mater, which is the outermost membrane covering the brain. A subdural hematoma (SDH) is blood from a damaged vein that collects in the space below the brain’s dura mater membrane.

Symptoms

Epidural Hematoma – 75% of EDHs are due to head injuries. Non-trauma causes include infections/abscesses, coagulopathy, hemorrhagic tumors, and/or vascular malformations, and are not detailed here. S/S of a traumatic EDH can occur within minutes, hours, or even many hours after injury and range from mild to severe:

  • Severe headache
  • Nausea/vomiting
  • Enlarged pupil in one eye
  • Confusion
  • Slurred speech
  • Dizziness
  • Single-sided body weakness
  • Seizures
  • Breathing problems
  • Loss of brain function
  • Coma
  • Death

Subdural Hematoma – SDHs, not surprisingly, are most commonly caused by head injures like falls, car or bike accidents, sports, etc. S/S can appear immediately or can develop over weeks or months and include:

  • Headache that doesn’t go away
  • Confusion/drowsiness
  • Nausea/vomiting
  • Slurred speech
  • Vision changes
  • Dizziness, loss of balance, difficulty walking
  • Single-sided body weakness
  • Memory loss, personality changes, disorientation
  • Enlarged heads in babies
  • Paralysis
  • Seizures
  • Breathing problems
  • LOC, coma
  • Death

Diagnosis

In addition to the standard physical exam, CT or MRI scans remain the standard of care when diagnosing EDHs and SDHs. EDHs appear as convex, or lens-shaped defects, while SDHs are concave, or crescent-shaped.

Treatments for EDH/SDH

Treatment for both types of hematomas is surgical – though the procedures themselves can differ.

The preferred surgery for an EDH is a craniotomy and hematoma evacuation. A portion of the skull is removed and the hematoma is evacuated. Once satisfied that any obvious sites of bleeding have been addressed, the skull bone is reattached with tiny screws.

Another approach is decompression surgery. One or more holes are drilled into the skull and the hematoma is drained, thus relieving the pressure on the brain. The drain might be left in place for several days to allow complete draining.

SDHs – are treated with decompression surgery, which is described above. Additional surgery may be warranted to remove large or thick blood clots that could be present. Drains are, more often than not, left in place for several days to assure drainage is complete.

ICD-10-PCS Codes

Evacuation

          Hematoma see Extirpation

          Other Fluid see Drainage

Extirpation

0 Medical and Surgical

0 Central Nervous System and Cranial Nerves

C Extirpation: Taking or cutting out solid matter from a body part

Body Part

Approach

Device

Qualifier

Character 4

Character 5

Character 6

Character 7

3   Epidural Space, Intracranial

0   Open

3   Percutaneous

4   Percutaneous Endoscopic

Z   No Device

Z   No Qualifier

4   Subdural Space, Intracranial

0   Open

3   Percutaneous

4   Percutaneous Endoscopic

Z   No Device

Z   No Device

 

Drainage

0 Medical and Surgical

0 Central Nervous System and Cranial Nerves

9 Drainage: Taking or letting out fluids and/or gases from a body part

Body Part

Approach

Device

Qualifier

Character 4

Character 5

Character 6

Character 7

3   Epidural Space, Intracranial

0   Open

3   Percutaneous

4   Percutaneous Endoscopic

Z   No Device

Z   No Qualifier

4   Subdural Space, Intracranial

0   Open

3   Percutaneous

4   Percutaneous Endoscopic

Z   No Device

Z   No Device

 

ICD-10-CM Codes for Traumatic Epidural and Subdural Hematomas

S06.4X

Epidural Hemorrhage

 

Extradural hemorrhage NOS; Extradural hemorrhage (traumatic)

S06.4X0

Epidural hemorrhage without LOC

S06.4X1

Epidural hemorrhage with LOC of 30 minutes or less

S06.4X2

Epidural hemorrhage with LOC of 31 minutes to 59 minutes

S06.4X3

Epidural hemorrhage with LOC of1 hour to 5 hour 59 minutes

S06.4X4

Epidural hemorrhage with LOC of 6 hours to 24 hours

S06.4X5

Epidural hemorrhage with LOC greater than 24 hours with return to pre-existing conscious level

S06.4X6

Epidural hemorrhage with LOC greater than 24 hours without return to pre-existing conscious level with patient surviving

S06.4X7A

Epidural hemorrhage with LOC of any duration with death due to brain injury prior to regaining consciousness

S06.4X8A

Epidural hemorrhage with LOC of any duration with death due to other causes prior to regaining consciousness

S06.4X9

Epidural hemorrhage with LOC of unspecified duration

 

Reminder: LOC = loss of consciousness

S06.5X

Traumatic Subdural Hemorrhage

S06.5X0

Traumatic subdural hemorrhage without LOC

S06.5X1

Traumatic subdural hemorrhage with LOC of 30 minutes or less

S06.5X2

Traumatic subdural hemorrhage with LOC of 31 minutes to 59 minutes

S06.5X3

Traumatic subdural hemorrhage with LOC of1 hour to 5 hour 59 minutes

S06.5X4

Traumatic subdural hemorrhage with LOC of 6 hours to 24 hours

S06.5X5

Traumatic subdural hemorrhage with LOC greater than 24 hours with return to pre-existing conscious level

S06.5X6

Traumatic subdural hemorrhage with LOC greater than 24 hours w/out return to pre-existing conscious level with patient surviving

S06.5X7

Traumatic subdural hemorrhage with LOC of any duration with death due to brain injury prior to regaining consciousness

S06.5X8

Traumatic subdural hemorrhage with LOC of any duration with death due to other causes prior to regaining consciousness

S06.5X9

Traumatic subdural hemorrhage with LOC of unspecified duration

REFERENCES:

Leave a Reply

Your email address will not be published. Required fields are marked *

Sign Up For MRA Blog Updates!

Recent Posts