Epidural hemorrhage w/o loss of consciousness, init encntr

This code signifies bleeding into the epidural space of the brain, located between the dura mater and the skull, without the patient experiencing a loss of consciousness. This condition is typically caused by trauma, often involving a skull fracture that lacerates a meningeal artery.

Apply this code when documentation clearly indicates an epidural hemorrhage resulting from an injury, and the patient remained conscious throughout the event. This code is specifically for the initial treatment or evaluation of the injury. Supporting documentation would include imaging reports (e.g., CT scan) confirming the hemorrhage and physician notes detailing the patient's mental status.

• Ensure documentation explicitly states "without loss of consciousness" to use this specific code.
• Confirm the encounter is the initial one for the injury; subsequent encounters would use a different seventh character.
• Always code the underlying cause of the injury (e.g., fall, motor vehicle accident) as an external cause code.