Neurosurgery Coding Alert

Question: Please suggest diagnosis code for neck and scalp hematomas. Our surgeon has documented these diagnoses in two different patients. The patient with the neck hematoma also was diagnosed neurofibromatosis and had undergone multiple surgeries in the past. This patient developed a spontaneous cervical hematoma. The second patient with the scalp hematoma developed one after a fall. What should I report?

Florida Subscriber

Answer: For both patients, you can report ICD-9 code 920 (Contusion of face scalp and neck except eye[s]). This code applies to bruise without fracture or open wound as well as hematoma without fracture or open wound.

With ICD-10 going effective later this year, you will need to be more specific for locations when coding for head and neck hematomas. You will report ICD-10 S00.03XA (Contusion of scalp, initial encounter) for hematoma of scalp and code S10.83XA (Contusion of other specified part of neck, initial encounter) for hematoma of the neck. The ICD-9 code 920 also maps to a number of other options. The ICD-10 options are listed below:

• S00.93XA, Contusion of unspecified part of head, initial encounter
• S10.93XA, Contusion of unspecified part of neck, initial encounter
• S00.33XA, Contusion of nose, initial encounter
• S00.431A, Contusion of right ear, initial encounter
• S00.432A, Contusion of left ear, initial encounter
• S00.439A, Contusion of unspecified ear, initial encounter
• S00.531A, Contusion of lip, initial encounter
• S00.532A, Contusion of oral cavity, initial encounter
• S00.83XA, Contusion of other part of head, initial encounter
• S10.0XXA, Contusion of throat, initial encounter