Hematoma ICD-10-CM Codes

What are Hematoma ICD-10-CM Codes?

Hematomas are collections of clotted blood outside the blood vessels, typically within soft tissue or subcutaneous tissue. In the ICD-10-CM system, hematomas are classified under multiple codes depending on their location, cause (traumatic vs. nontraumatic), and encounter type. One commonly used diagnosis code is M79.81 – Nontraumatic Hematoma of Soft Tissue, which applies to hematomas unrelated to trauma that involve the skin, muscle, or other soft tissue structures.

In addition to M79.81, providers should search for ICD-10 codes specific to the site, cause, and severity of the hematoma, especially if it involves complications from procedures, the endocrine system organ, thoracic aorta, or other parts of the body. Some hematomas result from injury, while others occur due to surgery, blood thinners, or other medical procedures.

Which Hematoma ICD-10-CM Codes are billable? 

Yes, M79.81 is billable. Additional billable codes include those specifying traumatic subdural hemorrhage, subdural hematoma, and hemorrhage and hematoma as intraoperative complications or postprocedural complications, depending on whether the hematoma occurred during or after a dermatologic procedure, ophthalmic procedure, or other procedure.

These codes often include modifiers for initial encounter, subsequent encounter, or sequela, as well as notations for unspecified site or unspecified duration.

Clinical information

• Hematomas are clotted area of blood outside the large blood vessels, usually located in the surrounding tissue. 
• Hematomas have different types depending on the location. Some areas where one can have a hematoma are the ear, under the nail, scalp, nose, spleen, liver, and between the internal lining of the brain and brain tissue. 
• Anything that damages the walls of the blood vessels that can cause the blood to leak, like injuries and trauma, can cause hematomas. However, patients may also have hematomas or have a higher risk of developing hematomas because of surgery or blood thinners.
• Symptoms vary depending on the location and severity. Superficial hematoma symptoms may be redness, inflammation, swelling, discoloration, tenderness, and pain. Meanwhile, hematomas in the skull may be severe headache, drowsiness, loss of consciousness, hearing loss, difficulty swallowing/moving an arm or leg, and uneven pupils. 
• Diagnosis will vary depending on the location. However, a practitioner will generally do a physical examination and ask for the patient’s medical history to diagnose hematoma. 
• To diagnose internal hematomas, the patient may be asked to undergo additional imaging tests.
• Superficial hematomas usually require rest and ice packs to alleviate symptoms and heal. For more severe cases, treatment may be a particular prescription/over-the-counter pain relievers or surgical drainage.