PROCEDURE

Question

The consent form was signed by the parents, and the patient was taken to the operating room. She was anesthetized, and the right frontotemporal region was prepped and draped. A burr hole, using a rounded tip, was made into the skull. Immediate evacuation and decompression resulted. The patient’s vitals were stable, and she was discharged to the neurosurgeon for evaluation of a craniotomy.

Note: External cause code(s) apply.

ICD-10 code
S06.5x9A
ICD-10 code
S06.5x9D
ICD-10 code
S06.5x9S

Answer 1

ICD-10 code: S06.5x9A - Unspecified intracranial injury, right side, initial encounter
ICD-10 code: S06.5x9D - Unspecified intracranial injury, right side, subsequent encounter
ICD-10 code: S06.5x9S - Unspecified intracranial injury, right side, sequela