Contusion of scalp, initial encounter

This code signifies a bruise or superficial injury to the soft tissues of the scalp, resulting from blunt force trauma, without an open wound. It indicates damage to capillaries and other small blood vessels beneath the skin, leading to discoloration and swelling.

Apply this code for patients presenting with a closed head injury manifesting as a scalp contusion, such as from a fall or direct impact. Documentation should clearly state "scalp contusion" and specify that it is the initial treatment for this particular injury.

• Ensure documentation specifies "initial encounter" for this specific injury. Subsequent encounters for the same contusion would use the appropriate subsequent encounter code.
• Do not use this code if there is an open wound, laceration, or abrasion of the scalp; instead, refer to codes within the S01 category.
• Always code any associated intracranial injuries (e.g., concussion, intracranial hemorrhage) separately and sequence them appropriately based on the encounter's primary reason.