ICD Code S06.360A

ICD code S06.360A is traumatic bleeding in the brain (cerebrum) from an unspecified cause, with no loss of consciousness, during the patient's initial medical encounter for this injury.

1. Evidence of traumatic injury to the cerebrum resulting in hemorrhage

2. No specification of the exact location or type of cerebral hemorrhage

3. No loss of consciousness at any point following the injury

4. Patient is being seen for the initial encounter related to this traumatic event

5. Clinical documentation supports trauma as the cause of the cerebral hemorrhage

6. Symptoms may include headache, nausea, vomiting, neurological deficits, or altered mental status, but without any documented loss of consciousness

Relevant CPT codes that may be used to treat ICD code S06.360A include:

- 99221–99223 (Initial hospital care, per day, for the evaluation and management of a patient)

- 99231–99233 (Subsequent hospital care, per day, for the evaluation and management of a patient)

- 61312 (Craniectomy or craniotomy, decompression of intracranial hemorrhage)

- 61154 (Burr hole(s) with evacuation of hematoma)

- 70450 (CT scan, head or brain; without contrast)

- 70460 (CT scan, head or brain; with contrast)

- 70470 (CT scan, head or brain; without and with contrast)

- 70551–70553 (MRI brain, without/with contrast)

- 96365 (Intravenous infusion, for therapy/diagnosis, initial, up to 1 hour)

- 36415 (Collection of venous blood by venipuncture)

- 85025 (Complete blood count, automated and automated differential WBC count)

CPT code selection should be based on the specific services rendered and clinical documentation.

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