2024 ICD-10-CM Diagnosis Code S09.90XD

Unspecified injury of head, subsequent encounter

ICD-10-CM Code:
S09.90XD
ICD-10 Code for:
Unspecified injury of head, subsequent encounter
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Not chronic
Code Navigator:

Code Classification

  • Injury, poisoning and certain other consequences of external causes
    (S00–T88)
    • Injuries to the head
      (S00-S09)
      • Other and unspecified injuries of head
        (S09)

S09.90XD is a billable diagnosis code used to specify a medical diagnosis of unspecified injury of head, subsequent encounter. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

S09.90XD is a subsequent encounter code, includes a 7th character and should be used after the patient has completed active treatment for a condition like unspecified injury of head. According to ICD-10-CM Guidelines a "subsequent encounter" occurs when the patient is receiving routine care for the condition during the healing or recovery phase of treatment. Subsequent diagnosis codes are appropriate during the recovery phase, no matter how many times the patient has seen the provider for this condition. If the provider needs to adjust the patient's care plan due to a setback or other complication, the encounter becomes active again.

Unspecified diagnosis codes like S09.90XD are acceptable when clinical information is unknown or not available about a particular condition. Although a more specific code is preferable, unspecified codes should be used when such codes most accurately reflect what is known about a patient's condition. Specific diagnosis codes should not be used if not supported by the patient's medical record.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Bleeding from nose
  • Chorea due to and following injury of head
  • Closed injury of head
  • Closed wound of head
  • Cranial cerebrospinal fluid leak
  • Friction alopecia
  • Head and neck injury
  • Headache due to injury of head and neck
  • Hemichorea
  • Hemichorea due to head injury
  • Injury of back of head
  • Injury of forehead
  • Injury of head
  • Injury of head and/or neck
  • Injury of head with otorrhagia
  • Injury of head with rhinorrhagia
  • Injury of upper respiratory tract
  • Language disorder associated with thought disorder
  • Leak of cranial cerebrospinal fluid due to and following injury of head
  • Major head injury
  • Metal foreign body in forehead
  • Minor head injury
  • Moderate head injury
  • Multiple injuries of bone of cranium
  • Multiple injuries of head
  • Multiple injuries of head and chest
  • Multiple injuries of thorax
  • Non-accidental injury
  • Non-accidental injury to child
  • Non-accidental traumatic head injury to child
  • Parkinsonism due to and following injury of head
  • Posttraumatic headache
  • Post-traumatic mutism
  • Scalp injury
  • Traumatic alopecia
  • Traumatic epistaxis
  • Vertigo preceded by head injury
  • Wig friction

Clinical Classification

Coding Guidelines

The appropriate 7th character is to be added to each code from block Other and unspecified injuries of head (S09). Use the following options for the aplicable episode of care:

  • A - initial encounter
  • D - subsequent encounter
  • S - sequela

Present on Admission (POA)

S09.90XD is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA IndicatorReason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert S09.90XD to ICD-9-CM

  • ICD-9-CM Code: V58.89 - Other specfied aftercare
    Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education


Head Injuries

Chances are you've bumped your head before. Often, the injury is minor because your skull is hard and it protects your brain. But other head injuries can be more severe, such as a skull fracture, concussion, or traumatic brain injury.

Head injuries can be open or closed. A closed injury does not break through the skull. With an open, or penetrating, injury, an object pierces the skull and enters the brain. Closed injuries are not always less severe than open injuries.

Some common causes of head injuries are falls, motor vehicle accidents, violence, and sports injuries.

It is important to know the warning signs of a moderate or severe head injury. Get help immediately if the injured person has:

  • A headache that gets worse or does not go away
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • An inability to wake up
  • Dilated (enlarged) pupil in one or both eyes
  • Slurred speech
  • Weakness or numbness in the arms or legs
  • Loss of coordination
  • Increased confusion, restlessness, or agitation

Doctors use a neurologic exam and imaging tests to make a diagnosis. Treatment depends on the type of injury and how severe it is.

NIH: National Institute of Neurological Disorders and Stroke


[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.