Nontraumatic subdural hemorrhage, unspecified

This code describes bleeding into the subdural space, located between the dura mater and arachnoid mater, that is not caused by an external injury or trauma. It represents a spontaneous accumulation of blood in this area of the brain.

Use this code when documentation clearly states a subdural hemorrhage without any mention of trauma as the cause. This often applies to cases where the etiology is unknown or attributed to underlying medical conditions like coagulopathies or cerebral aneurysms.

• Do not use this code if trauma is documented as the cause; instead, refer to codes in the S06.5- category.
• Always seek clarification if the documentation is ambiguous regarding the traumatic or nontraumatic nature of the hemorrhage.
• Sequence this code as the primary diagnosis when it is the reason for the encounter, followed by any underlying conditions contributing to the hemorrhage.