Cephalhematoma due to birth injury

This code represents a collection of blood under the periosteum of a newborn's skull bone, specifically caused by trauma during the birth process. It is a subperiosteal hemorrhage that does not cross suture lines, differentiating it from a caput succedaneum.

Apply this code when documentation clearly indicates a cephalhematoma diagnosed in a neonate, and the etiology is directly attributed to birth injury. Supporting documentation should include a physical exam noting a firm, localized swelling on the infant's head that does not cross suture lines, along with a history of a difficult or traumatic delivery.

• Differentiate from caput succedaneum (P12.1), which is a diffuse, edematous swelling that crosses suture lines.
• Ensure the documentation explicitly links the cephalhematoma to a birth injury; otherwise, consider codes for unspecified birth injury or other neonatal head injuries.
• Sequence this code as a principal diagnosis if it is the primary reason for admission or encounter, or as a secondary diagnosis if it is a co-morbidity.