ICD 10 CM S06.5 | Description & Clinical Information

ICD 10 S06.5 describes a medical condition characterized by the presence of bleeding beneath the dura, which is the outer membrane that covers the brain and spine, resulting from a traumatic brain injury caused by various factors such as blunt trauma from a fall or assault, or a deceleration injury to the brain that occurs when the head comes into contact with a solid object during a motor vehicle collision.

Official Description Of S06.5

The ICD 10 CM book defines ICD 10 code S06.5 as:

When To Use S06.5

The diagnosis described by the ICD-10-CM code S06.5 is traumatic subdural hemorrhage, a condition that can cause various symptoms and complications. Traumatic subdural hemorrhage occurs when blood accumulates between the dura mater layer and the arachnoid mater layer of the meninges surrounding the brain, usually resulting from head trauma.

The symptoms of traumatic subdural hemorrhage include unconsciousness, seizures, nausea and vomiting, and increased intracranial pressure or ICP. The patient may also experience a headache, temporary or permanent amnesia, physical and mental disability, impaired cognitive function, and difficulty communicating once they regain consciousness.

Medical providers typically diagnose traumatic subdural hemorrhage based on the patient’s history of trauma and physical examination, paying particular attention to the patient’s response to stimuli and pupil dilation. The Glasgow Coma Scale is also used to assess the patient’s level of consciousness, with scores ranging from 3 to 15 depending on the severity of the patient’s condition. Imaging techniques such as computed tomography or CT angiography and magnetic resonance imaging or MR angiography are used to identify and monitor the hemorrhage, while electroencephalography is used to evaluate brain activity.

The treatment options for traumatic subdural hemorrhage depend on the severity of the injury. Medications such as sedatives, corticosteroids, antiseizure drugs, and analgesics may be prescribed to manage the patient’s symptoms. The patient’s airway and circulation may need to be stabilized, and their neck or head may need to be immobilized. Any associated problems, such as increased intracranial pressure, may need to be addressed, and in some cases, surgery may be necessary to implant an ICP monitor or evacuate the hematoma.

It is crucial to diagnose and treat traumatic subdural hemorrhage promptly, as it can lead to further complications, such as cerebral edema, brain herniation, or even death.

In conclusion, traumatic subdural hemorrhage is a severe condition that can result from head trauma. It can cause various symptoms and complications and requires prompt diagnosis and treatment. Medical providers use imaging techniques and neurologic assessments to diagnose and manage the condition, applying medications, stabilization, and surgery, if necessary. Medical coders play an essential role in correctly coding and documenting the diagnosis for insurance claims and patient medical records.