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S00.03XA
ICD-10-CM
Scalp Hematoma

Learn about scalp hematoma diagnosis, including clinical documentation, ICD-10 codes (S00.0, S00.1, S00.8, S00.9), medical billing, and healthcare best practices. Understand subgaleal hematoma, cephalohematoma, and other related head injuries. Find information on symptoms, treatment, and proper coding for accurate reimbursement. Explore resources for physicians, nurses, and other healthcare professionals regarding scalp hematoma management and documentation.

Also known as

Scalp Contusion
Head Bump
scalp bruise
+2 more

Diagnosis Snapshot

Key Facts
  • Definition : A collection of blood outside blood vessels between the skull and scalp skin.
  • Clinical Signs : Swelling, pain, tenderness, bruising, lump, discoloration on scalp.
  • Common Settings : Trauma, head injury, falls, sports injuries, childbirth.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S00.03XA Coding
S00-S09

Injuries to the head

Covers injuries to the scalp, skull, and brain.

S00.0-S00.9

Superficial injury of head

Includes contusions and open wounds of the scalp.

S00.3-S00.5

Contusion of scalp

Specifically addresses contusions and hematomas of the scalp.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Traumatic injury cause hematoma?

  • Yes

    Open wound present?

  • No

    Newborn (birth injury)?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Scalp Hematoma
Subgaleal Hemorrhage
Cephalohematoma

Documentation Best Practices

Documentation Checklist
  • Document size, location, and appearance of scalp hematoma.
  • Detailed record of injury mechanism and timing.
  • Neurological exam findings (e.g., GCS, focal deficits).
  • Associated symptoms (e.g., pain, nausea, dizziness).
  • Document diagnostic methods (e.g., palpation, imaging).

Coding and Audit Risks

Common Risks
  • Unspecified Trauma Code

    Using unspecified injury codes (e.g., S00.9-) without proper documentation of the cause can lead to claim denials and inaccurate data.

  • Missed Co-morbidities

    Failing to code associated injuries or conditions (e.g., concussion, skull fracture) impacts reimbursement and quality metrics.

  • Documentation Deficiencies

    Lack of specific details about the hematoma (size, location, etiology) hinders accurate coding and CDI specialist queries.

Mitigation Tips

Best Practices
  • Accurate ICD-10 coding (S00.xyz) for scalp hematoma location/severity.
  • Detailed HPI documentation: mechanism of injury, symptoms onset.
  • Consistent CDI queries for precise documentation of hematoma size/depth.
  • Timely follow-up documentation to track resolution and prevent complications.
  • Adhere to payer-specific guidelines for appropriate imaging/treatment coding.

Clinical Decision Support

Checklist
  • Hx: Mechanism of scalp injury (fall, blunt trauma)
  • PE: Palpable fluctuant swelling, tenderness
  • Imaging (CT/MRI): Confirm hematoma, rule out skull fx
  • Assess neuro status: GCS, focal deficits
  • Document size, location for accurate coding (ICD-10 S00.xyz)

Reimbursement and Quality Metrics

Impact Summary
  • Scalp Hematoma: Reimbursement and Quality Metrics Impact Summary
  • Keywords: ICD-10 S00.0-S00.9, CPT codes, medical billing, coding accuracy, hospital reporting, denials, present on admission (POA), quality measures, patient safety indicators (PSI), value-based care
  • Impact 1: Accurate POA status crucial for proper DRG assignment & reimbursement.
  • Impact 2: Coding specificity (traumatic vs. non-traumatic) impacts severity & resource utilization.
  • Impact 3: Miscoding can lead to claim denials, reduced revenue, and inaccurate quality reporting.
  • Impact 4: Scalp hematoma documentation influences PSI 03 (pressure ulcer rate) if related to hospital procedures.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Document trauma cause
  • Specify location, size
  • Rule out skull fracture
  • Code S00.5 for scalp hematoma
  • Consider 7th character injury stage

Documentation Templates

Patient presents with a scalp hematoma, likely secondary to [documented cause of injury, e.g., fall, blunt trauma, impact].  On examination, a palpable, fluctuant swelling is noted on the [location on scalp, e.g., occipital, parietal, frontal] region of the scalp.  The overlying skin exhibits [description of skin findings, e.g., ecchymosis, erythema, abrasion, laceration].  The patient reports [patient-reported symptoms, e.g., localized pain, tenderness, headache, dizziness]. Neurological examination is [neurological status, e.g., grossly intact, unremarkable, with focal deficits].  Differential diagnoses include subgaleal hematoma, cephalohematoma, and skull fracture.  Imaging studies [mention if any imaging was ordered, e.g., skull X-ray, CT scan of the head] were [results of imaging, e.g., negative for skull fracture, revealed no intracranial bleeding, confirmed subgaleal hematoma].  Diagnosis of scalp hematoma confirmed.  Treatment plan includes [mention treatment plan, e.g., ice packs, analgesics, observation, surgical intervention if needed].  Patient education provided regarding wound care, signs of infection, and when to seek medical attention.  Follow-up scheduled in [duration, e.g., one week] to monitor healing progress and assess for any complications.  ICD-10 code: [appropriate ICD-10 code, e.g., S00.00].
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