ICD Code S09.90

ICD code S09.90 is an unspecified injury of the head.

1. Patient presents with evidence of a head injury.

2. No loss of consciousness is documented.

3. No specific intracranial injury, skull fracture, or other defined head injury is identified.

4. Symptoms may include headache, scalp tenderness, dizziness, confusion, or minor scalp lacerations/abrasions without further specification.

5. Diagnostic imaging (if performed) does not reveal a more specific injury.

6. The clinical assessment concludes that the head injury cannot be further classified based on available information.

Relevant CPT codes that may be used to treat ICD code S09.90 include:

- 99281–99285 (Emergency department visits)

- 99201–99205 (New patient office or other outpatient visits)

- 99211–99215 (Established patient office or other outpatient visits)

- 70450 (CT head/brain without contrast)

- 70460 (CT head/brain with contrast)

- 70470 (CT head/brain without and with contrast)

- 70336 (MRI brain)

- 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa)

- 96372 (Therapeutic, prophylactic, or diagnostic injection)

- 96360–96361 (IV infusion, hydration)

- 96365–96366 (IV infusion, therapy)

- 96374 (IV push, therapeutic/prophylactic/diagnostic)

- 99499 (Unlisted evaluation and management service)

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

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