Back to HomeBeta

ICD-10 Coding for History of Subdural Hematoma(Z86.73, S06.5X-, I62.0-)

Complete ICD-10-CM coding and documentation guide for History of Subdural Hematoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

History of SDHPast Subdural Hematoma

Quick Navigation

Related ICD-10 Code Ranges

Complete code families applicable to History of Subdural Hematoma

Z86.73Primary Range

Personal history of diseases of the nervous system and sense organs

Used for documenting a resolved subdural hematoma with no active symptoms.

S06.5X-

Traumatic subdural hemorrhage

Used for current or recurrent subdural hematoma related to trauma.

I62.0-

Nontraumatic subdural hemorrhage

Used for documenting spontaneous subdural hematoma history.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
Z86.73Personal history of subdural hematomaUse when the subdural hematoma is resolved and there are no active symptoms.
  • CT/MRI confirming resolution
  • No active symptoms
S06.5X-Traumatic subdural hemorrhageUse for active or recurrent traumatic subdural hematoma.
  • CT/MRI showing active hematoma
  • Documentation of traumatic event
I62.0-Nontraumatic subdural hemorrhageUse for active or recurrent nontraumatic subdural hematoma.
  • CT/MRI showing active hematoma
  • No traumatic event documented

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for history of subdural hematoma

Essential facts and insights about History of Subdural Hematoma

The ICD-10 code for a history of subdural hematoma is Z86.73, used when the condition is resolved and there are no active symptoms.

Primary ICD-10-CM Codes for history of subdural hematoma

Z86.73
Personal history of subdural hematoma
Billable Code

Decision Criteria

clinical Criteria

  • Hematoma is resolved with no active symptoms.

coding Criteria

  • Do not use if there are active symptoms or ongoing treatment.

Applicable To

  • Resolved subdural hematoma

Excludes

  • Current subdural hematoma

Clinical Validation Requirements

  • CT/MRI confirming resolution
  • No active symptoms

Code-Specific Risks

  • Incorrectly using for active conditions

Coding Notes

  • Ensure documentation specifies the resolution of the hematoma.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

External causes of falls

W00-W19
Use to specify the cause of trauma.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Traumatic subdural hemorrhage

S06.5X-
Used for active or recurrent traumatic subdural hematoma.

Nontraumatic subdural hemorrhage

I62.0-
Used for active or recurrent nontraumatic subdural hematoma.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting History of Subdural Hematoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z86.73.

Impact

Clinical: Misleading patient history, Regulatory: Potential audit issues, Financial: Incorrect billing

Mitigation Strategy

Use specific terms like 'resolved' and 'traumatic/nontraumatic'.

Impact

Reimbursement: Incorrect DRG assignment, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records

Mitigation Strategy

Use S06.5X- or I62.0- for active cases.

Impact

Using Z86.73 for active conditions

Mitigation Strategy

Regular training on code differentiation

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for History of Subdural Hematoma, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for History of Subdural Hematoma

Use these documentation templates to ensure complete and accurate documentation for History of Subdural Hematoma. These templates include all required elements for proper coding and billing.

Routine follow-up for resolved SDH

Specialty: Primary Care

Required Elements

  • Patient history
  • Imaging results
  • Current symptoms

Example Documentation

Patient with history of traumatic subdural hematoma (Z86.73) in 2020, now presenting for routine follow-up. Last CT head 6 months ago showed complete resolution.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has SDH history.
Good Documentation Example
Patient with history of traumatic subdural hematoma (Z86.73) resolved as of 2020, confirmed by CT.
Explanation
The good example specifies the type, resolution, and confirmation method.

Need help with ICD-10 coding for History of Subdural Hematoma? Ask your questions below.

Ask about any ICD-10 CM code, or paste a medical note

We build tools for
clinician happiness.

Learn More at Freed.ai
Back to HomeBeta

Built by Freed

Try Freed for free for 7 days.

Learn more

Helpful Links

How ICD 10 AI Lookup WorksContact UsPrivacy Policy