S06.5X1A Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter

ICD10CM code

#### Name of the Condition
- **Traumatic Subdural Hemorrhage with Loss of Consciousness of 30 Minutes or Less, Initial Encounter**
- Sometimes referred to as a **subdural hematoma** with mild traumatic brain injury.

#### Summary
A traumatic subdural hemorrhage is a type of brain injury where blood gathers between the dura mater and the brain due to trauma. In this case, the individual experiences a brief loss of consciousness lasting up to 30 minutes following the injury.

#### Causes
- Physical trauma to the head, such as from falls, vehicle accidents, or sports injuries, is the primary cause.
- In some instances, anticoagulant medications can exacerbate the bleeding following minor head impacts.

#### Risk Factors
- Older age, due to increased fragility of blood vessels.
- Participation in contact sports or hazardous activities.
- Use of blood-thinning medication.
- Conditions such as alcohol abuse, which may increase fall risk.

#### Symptoms
- Headache
- Nausea or vomiting
- Dizziness or confusion
- Brief loss of consciousness (30 minutes or less)
- Memory disturbance

#### Diagnosis
- **CT Scan**: Primary imaging modality to detect and assess the extent of bleeding.
- **MRI**: Used for more detailed brain imaging.
- **Neurological examination**: To assess cognitive and motor function.

#### Treatment Options
- **Observation**: For minor cases where spontaneous resolution is possible.
- **Medication**: To manage symptoms such as pain or nausea.
- **Surgery**: In severe cases, surgical intervention may be needed to relieve pressure on the brain.
  - **Burr hole drainage**: To evacuate the hematoma.
  - **Craniotomy**: For larger or more complicated hemorrhages.

#### Prognosis and Follow-Up
- Most individuals recover fully with proper management; however, monitoring is essential to ensure no progression of symptoms.
- Regular follow-up visits for neurological evaluations are advised.

#### Complications
- Persistent headaches or neurological deficits.
- Potential for recurrent bleeding.
- Development of chronic subdural hematoma.

#### Lifestyle & Prevention
- Wearing protective gear during sports.
- Implementing fall prevention strategies for at-risk individuals.
- Regular medical review if on anticoagulant therapy.

#### When to Seek Professional Help
- Sudden, severe headache following head injury.
- Repeated vomiting or prolonged confusion.
- Worsening symptoms after initial improvement.

#### Additional Resources
- **Brain Injury Association of America**: [www.biausa.org](https://www.biausa.org)
- **Centers for Disease Control and Prevention (CDC)**: Information on traumatic brain injuries.

#### Tips for Medical Coders
- Ensure the correct capture of initial encounter versus subsequent encounters.
- Differentiate this code from other subdural hemorrhages with different durations of consciousness loss.
- Review all associated charts for accurate documentation of loss of consciousness duration.

Medical Policies and Guidelines for Traumatic subdural hemorrhage with loss of consciousness of 30 minutes or less, initial encounter

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