ICD-10 Coding and Documentation of Subdural Hematoma

Hello everyone and welcome to our podcast series. My name is Natalie Tornese and I’m a Senior Solutions Manager with Outsource Strategies International. I wanted to take this opportunity to talk to you about documenting and coding Subdural Hematoma. Head injury is a serious condition that requires immediate medical attention. Generally, a person suffering from a head injury may not initially experience any feelings of being sick, but bleeding can occur within the skull. Internal bleeding can lead to serious consequences, including severe brain damage and even death. One type of internal bleeding in the skull is called subdural hematoma. Also called a subdural hemorrhage, this condition occurs when a vein located below the skull ruptures and starts to bleed. The blood collects between the skull and the surface of the brain. As the volume of hematoma increases, brain parenchyma gets compressed and displaced, and the intracranial pressure may rise and cause herniation, leading to unconsciousness and death. Subdural hematomas can be caused by minor accidents to the head, major trauma, or the spontaneous bursting of a blood vessel in the brain which is called aneurysm.

Treatment for this head injury is generally based on the type and severity of the injury. Typically, surgery is recommended for most subdural hematomas. However, very small hematomas may be carefully monitored first to see if they can heal without actually having an operation. Neurosurgeons or neurology specialists who provide appropriate treatment for this type of injuries should also ensure that the medical coding for this condition is properly done on their medical claims.

Subdural hematomas can either be acute or chronic. Acute subdural hematoma is the most dangerous type. It is usually caused by a vehicle accident, or a blow to the head or a fall from a height. Such cases form quickly and are often harder to treat. It is estimated that the death from an acute subdural hematoma is more than 50 percent. Chronic subdural hematoma is on the other hand occurred by mild or repeated head injuries. These are more common among older adults who repeatedly fall and hit their heads.

The symptoms of subdural hematoma can depend on the type of injury (whether it’s acute or chronic) and can vary from one person to another. Symptoms of the acute subdural hematoma occur rapidly following an injury. In cases of chronic subdural hematoma, symptoms are more likely to develop slowly or may not even develop at all.

Common symptoms include –

• Severe headache
• Vision problems
• Slurred speech
• Seizures
• Mood swings
• Loss of consciousness or passing out
• Dizziness
• Vomiting
• Confusion
• Apathy and weakness

Other potential risk factors that could increase a person’s chances of developing subdural hemorrhage include – patient’s age, medical conditions (that cause blood clotting issues), long-term alcohol use or abuse, blood thinners (such as warfarin or aspirin) and repeated head injuries (such as falls or sports).

It is to be diagnosed quickly and that is important. It is important so that the treatment programs can be initiated immediately. Timely treatment may help minimize the risk of severe complications and even death. In most cases, a head hemorrhage is quite difficult to diagnose as certain types do not depict any specific symptoms quickly or may not actually have an obvious cause.

As part of the initial diagnosis, physicians will conduct a thorough physical and neurological exam to check for blood pressure and pulse, reflexes and balance, vision (most importantly the way the eyes respond to light, they can ensure that the pupils are equal and reactive) and the patient’s ability to answer questions and remember things. Physicians ask several questions about – occurrence of any head injuries (past and present), pain symptoms developed, medications, medical health problems and alcohol, drug consumption habits.

There are several diagnostic tests like computed tomography (CT scan) magnetic resonance imaging (MRI) scans that can be conducted to get a clear picture of the different parts of the brain, skull, veins and other blood vessels and to check for any specific signs of blood clotting. If the physician identifies bleeding in any area, the source of the bleeding will be determined and a plan of action is developed to address the specific issue. In addition, neurologists will also check your blood pressure and heart rate and recommend a detailed blood test to check for the total blood count. A complete blood count measures your red blood cell and white blood cell count and your platelets. A low level of red blood cells can indicate significant blood loss.

Treatment options for subdural hemorrhage may mainly depend on the type and severity of the injury. Surgery will be recommended as the best option in most cases of subdural hemorrhage. Surgical techniques include craniotomy, where a section of the skull is temporarily removed in order to access and remove the hematoma and burr holes, which is a small hole made in the skull, when a tube is inserted through the hole that would help to drain blood clots. However, very small subdural hematomas may be carefully monitored if they heal.

When coding for this condition, you should refer to the ICD-10 codes that I have listed along with this transcript. You know that it coincide with the procedures performed.

With early treatment of these injuries, patients will have a better chance of full recovery. The speed of recovery does depend on the type and extent of damage the hematoma has caused to the brain. It is estimated that only 20 -30 percent of people can expect to see a full or nearly full recovery of brain functioning. Even after treatment for subdural hematomas, many patients are left with long-lasting problems, and weakness – weakness  in the  limbs,  mood swings, memory/concentration problems, seizures. In some cases, there are chances that the symptoms may come back and hence surgery is needed to drain the hematoma.

I hope this helps.

But always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.

Thanks so much for listening!