Subdural hemorrhage due to birth injury

This diagnosis code signifies bleeding into the subdural space of an infant's brain, directly resulting from trauma experienced during the birth process. This condition can lead to increased intracranial pressure and neurological deficits in the neonate.

Assign this code when documentation explicitly states a subdural hemorrhage in a newborn and clearly links its etiology to birth injury. Supporting documentation would include physician notes detailing the birth trauma, imaging reports confirming the subdural bleed, and a clear causal connection established by the clinician.

• Ensure the documentation specifies "birth injury" as the cause; otherwise, a non-traumatic subdural hemorrhage code may be more appropriate.
• Distinguish from subdural hemorrhages due to other causes (e.g., non-accidental trauma, coagulation disorders) which would be coded differently.
• Review imaging reports (e.g., CT, MRI) and neurological assessments to confirm the location and impact of the hemorrhage.