M79.81 Nontraumatic hematoma of soft tissue

ICD10CM code

#### Name of the Condition
- Nontraumatic Hematoma of Soft Tissue
- Also known as spontaneous hematoma or intramuscular hematoma when occurring within the muscle tissue.

#### Summary
Nontraumatic hematoma of soft tissue refers to bleeding that occurs outside of blood vessels and accumulates in the soft tissues without a preceding injury or trauma. This condition often results in swelling and skin discoloration in the affected area.

#### Causes
- Coagulation disorders (e.g., hemophilia, vitamin K deficiency)
- Use of anticoagulant medications (e.g., warfarin, heparin)
- Medical conditions like liver disease
- Rarely, spontaneous rupture of blood vessels 

#### Risk Factors
- Advanced age
- Use of blood-thinning medications
- Pre-existing blood clotting disorders
- Chronic diseases such as liver or kidney disease

#### Symptoms
- Localized pain and tenderness 
- Swelling and bruising in the affected area
- Skin discoloration that changes color over time
- Reduced mobility depending on the location

#### Diagnosis
- Physical examination to assess swelling and discoloration
- Imaging tests, such as ultrasound or MRI, to confirm hematoma presence and assess its size
- Blood tests to evaluate clotting function if a coagulation disorder is suspected

#### Treatment Options
- Observation and rest for minor hematomas
- Pain management with analgesics
- Elevating and applying cold compresses to reduce swelling
- Surgical intervention in severe cases to evacuate the hematoma
- Adjustment of anticoagulant medications under medical supervision

#### Prognosis and Follow-Up
- Generally favorable prognosis if treated appropriately
- Follow-up may include monitoring coagulation status and adjusting medications as needed
- Regular check-ups are important for individuals with underlying blood clotting disorders

#### Complications
- Infection of the hematoma
- Nerve compression leading to neuropathy
- Persistent swelling or cosmetic deformities
- In severe cases, compartment syndrome

#### Lifestyle & Prevention
- Avoid injuries and protect areas prone to bleeding
- Adhere to medication regimens as prescribed, especially anticoagulants
- Engage in activities that do not pose high risks of falls or bumps
- Maintain regular health check-ups for chronic conditions

#### When to Seek Professional Help
- Rapid swelling or severe pain develops
- Signs of infection, such as fever or redness, occur
- Hematoma does not resolve or worsens over time

#### Additional Resources
- The American Society of Hematology (www.hematology.org)
- National Hemophilia Foundation (www.hemophilia.org)
- Mayo Clinic's information on hematomas

#### Tips for Medical Coders
- Verify that the hematoma is nontraumatic in nature to accurately assign M79.81
- Double-check related conditions or medications that may have contributed to the hematoma
- Avoid conflating with traumatic hematoma; ensure no prior injuries are involved

Similar Codes