Scalp Hematoma ICD-10-CM Codes | 2025

What scalp hematoma ICD-10 codes can I use?

A scalp hematoma is generally coded under contusion of scalp in the ICD-10-CM system, as there is no specific code solely for "scalp hematoma." The following codes are used based on the encounter type and progression of care:

S00.03XA - Contusion of scalp, initial encounter

S00.03XA - Contusion of scalp, initial encounter is meant to be used on a patient confirmed to have a scalp contusion. “Contusion” is the medical term for “bruise.” These result from damage caused to small blood vessels.

This code is used when a scalp hematoma is diagnosed during the first medical visit and the patient is receiving active treatment. It applies to direct trauma resulting in a bruise, swelling, or bleeding under the skin of the scalp.

S00.03XD - Contusion of scalp, subsequent encounter

This is the same as S00.03XA, but this time, there's a subsequent encounter label, which means the patient is in the recovery phase and is still being given active/routine treatment.

Use this code when the patient returns for follow-up care after the initial diagnosis. It indicates that the active phase of treatment has ended, and the provider is monitoring healing or managing ongoing symptoms.

S00.03XS - Contusion of scalp, sequela

This is the same as S00.03XA, but there's a sequela label this time, which means the patient is dealing with the aftereffects of the problem.

This code is applied when a complication or residual effect of a scalp hematoma is being treated (e.g., chronic pain, scarring, or tissue damage). It reflects a sequela, meaning the current visit addresses long-term effects of the original injury.

Are these scalp hematoma ICD-10 codes billable?

Yes, all listed ICD-10-CM codes for scalp hematoma, including S00.03XA (initial encounter), S00.03XD (subsequent encounter), and S00.03XS (sequela), are valid and billable. These codes classify a scalp contusion, which includes hematoma of scalp, and are accepted for reimbursement when accurately documented during active treatment or follow-up care.

Clinical information

If a person has a scalp hematoma, they will have pools of blood in their head that form because blood vessels (especially the large ones) are damaged or ruptured. These hematomas are located between the scalp and the skull, specifically in the areas surrounding where the damage and ruptures occurred.

These hematomas can form as a result of physical trauma or injuries. Symptoms may include:

• Swelling or a raised area on the scalp
• Discoloration or bruising
• Tenderness or pain at the injury site
• In neonates, a soft, bulging area on the head

Here's the diagnosis and treatment:

• Physical examination to assess the extent of the injury
• Imaging studies (e.g., CT scan) if intracranial injury is suspected
• Monitoring for signs of increased intracranial pressure
• Most scalp hematomas resolve without intervention; however, large or expanding hematomas may require medical attention​

Synonyms include:

• Birth injury to scalp (if applicable to neonates)
• Blunt injury of scalp
• Bruise to head
• Bruise of scalp
• Contusion of scalp
• Closed injury of scalp
• Hematoma due to blunt trauma to scalp
• Hematoma of scalp
• Scalp trauma with hematoma