Find information on traumatic intracerebral hemorrhage diagnosis, including clinical documentation requirements, ICD-10 codes (S06.X), medical coding guidelines, and healthcare best practices. Learn about ICH management, treatment options, and prognosis. This resource offers guidance for physicians, nurses, coders, and other healthcare professionals dealing with traumatic brain injury and intracranial bleeding. Explore relevant symptoms, diagnostic criteria, and differential diagnoses related to intracerebral hematoma.
Also known as
Intracranial injury
Traumatic hemorrhage within the brain.
Cerebral laceration and contusion
Brain tissue tearing with associated bruising.
Nontraumatic intracerebral hemorrhage
Bleeding within the brain not caused by trauma. (For exclusion purposes)
Fracture of skull and facial bones
Skull fractures that may accompany brain hemorrhage.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the traumatic intracerebral hemorrhage atraumatic?
When to use each related code
| Description |
|---|
| Traumatic brain bleed within brain tissue. |
| Epidural Hematoma |
| Subdural Hematoma |
Missing or unclear documentation of hemorrhage location (right, left, bilateral) impacts correct ICD-10 code selection and reimbursement.
Insufficient documentation to distinguish between traumatic and nontraumatic ICH can lead to inaccurate coding and quality reporting.
Lack of clear documentation linking the ICH to the specific traumatic event may cause coding errors and affect injury severity scores.
Patient presents with signs and symptoms consistent with traumatic intracerebral hemorrhage (ICH). Onset of symptoms followed [Mechanism of injury, e.g., motor vehicle collision, fall] which occurred on [Date of injury]. Patient exhibits [Neurological deficits, e.g., altered mental status, focal weakness, headache, seizures, aphasia, visual disturbances]. Glasgow Coma Scale score is documented as [GCS score]. Initial computed tomography (CT) scan of the head without contrast reveals [Location and size of hemorrhage, e.g., a 2 cm x 3 cm hyperdense lesion within the right frontal lobe]. Differential diagnoses considered include subdural hematoma, epidural hematoma, and contusion. Neurosurgical consultation was obtained. Current management includes [Medications, e.g., anticonvulsants for seizure prophylaxis, blood pressure management], close neurological monitoring, and supportive care. Patient is admitted for further evaluation and management of traumatic brain injury and intracerebral bleeding. Prognosis is guarded. ICD-10 code S06.5 (Traumatic intracerebral hemorrhage) is applied. Continued monitoring for signs of increased intracranial pressure, herniation, and neurological deterioration is warranted. Plan for repeat CT scan in [Timeframe, e.g., 24 hours] to assess for hemorrhage expansion.