Coding Rules Current as at 18-Oct-2016 08: 31

Published 15 June 2015,
for implementation 01 July 2015.

Ref No: Q2922 | Published On: 15-Jun-2015 | Status: Current

SUBJECT: Subgaleal haematoma

Q:

What is the correct code to assign for a subgaleal haematoma not due to birth trauma?

A:

Subgaleal haematoma occurs when there is bleeding into the space between the skull periosteum and the scalp galea aponeurosis. This condition is commonly seen after traumatic birth in neonates but it may also occur after a fall or blow to the head. As the haemorrhage occurs outside the cranium it is not regarded as intracranial injury although an extensive subgaleal haematoma may require monitoring for signs of neurological deficits to exclude intracranial injury, especially where there is loss of consciousness.

A subgaleal haematoma should be coded to S00.05 Superficial injury of scalp, contusion following the index pathways:
Haematoma (skin surface intact) (traumatic) (see also Contusion)

and

Contusion (skin surface intact)

- scalp S00.05

with appropriate external cause codes.

Code also any closed head injury/loss of consciousness as per ACS 1905 Closed head injury/loss of consciousness/concussion.

Improvements to ICD-10-AM will be considered for a future edition.

References:

Agrawal, A. et al (2006). Delayed extensive subgaleal haematoma following head injury. Paediatric Oncall Journal. Retrieved from: http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=798&type=J&tid=&imgid=&reportid=158&tbltype

Luijkx,T., Jones, J. et al (2015). Subgaleal haematoma. Radiopaedia.org. Retrieved from: http://radiopaedia.org/articles/sub-galeal-haematoma