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ICD-10 Guide
ICD-10 CodesP12.2

P12.2

Billable

Epicranial subaponeurotic hemorrhage due to birth injury

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 P12.2 is a billable code used to indicate a diagnosis of epicranial subaponeurotic hemorrhage due to birth injury.

Key Diagnostic Point:

Epicranial subaponeurotic hemorrhage, also known as subgaleal hemorrhage, is a condition that occurs when there is bleeding between the skull and the aponeurosis of the scalp, typically resulting from trauma during delivery. This condition is often associated with the use of vacuum extraction or forceps during childbirth. The hemorrhage can lead to significant blood loss and may present with a fluctuating mass on the scalp, which can extend beyond the suture lines. It is crucial to differentiate this condition from caput succedaneum and cephalohematoma, which are also common birth injuries. Caput succedaneum is characterized by edema of the soft tissues of the head, while cephalohematoma involves bleeding between the skull and the periosteum. The management of epicranial subaponeurotic hemorrhage may require close monitoring and, in severe cases, intervention to prevent complications such as hypovolemic shock. Early recognition and appropriate coding are essential for effective treatment and resource allocation in neonatal care.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiation from similar conditions (caput succedaneum, cephalohematoma)
  • Variability in clinical presentation and severity
  • Potential for significant blood loss and complications
  • Documentation requirements for birth injury causation

Audit Risk Factors

  • Inadequate documentation of birth injury causation
  • Misclassification with caput succedaneum or cephalohematoma
  • Failure to document clinical monitoring and interventions
  • Inconsistent use of ICD-10 codes across providers

Specialty Focus

Medical Specialties

Neonatology

Documentation Requirements

Detailed documentation of the delivery method, clinical findings, and any interventions performed.

Common Clinical Scenarios

Newborns presenting with scalp swelling and fluctuating masses in the NICU, requiring monitoring for anemia.

Billing Considerations

Consideration of the infant's overall clinical status and potential need for blood transfusions.

Pediatrics

Documentation Requirements

Documentation of follow-up assessments and any developmental concerns related to birth injuries.

Common Clinical Scenarios

Pediatric follow-up visits for infants with a history of birth-related scalp injuries.

Billing Considerations

Monitoring for long-term effects of birth injuries on development.

Coding Guidelines

Inclusion Criteria

Use P12.2 When
  • According to the official ICD
  • 10 coding guidelines, accurate documentation of the birth injury's causation and clinical presentation is essential
  • Coders should ensure that the diagnosis aligns with the clinical findings and that all relevant details are captured in the medical record

Exclusion Criteria

Do NOT use P12.2 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99460CPT Code

Initial hospital care, per day, for evaluation and management of a normal newborn

Clinical Scenario

Used in conjunction with P12.2 for newborns requiring monitoring due to hemorrhage.

Documentation Requirements

Document the clinical status and any interventions related to the hemorrhage.

Specialty Considerations

Neonatologists should ensure comprehensive documentation of the newborn's condition.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including epicranial subaponeurotic hemorrhage. This specificity aids in better tracking of outcomes and resource allocation in neonatal care.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including epicranial subaponeurotic hemorrhage. This specificity aids in better tracking of outcomes and resource allocation in neonatal care.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including epicranial subaponeurotic hemorrhage. This specificity aids in better tracking of outcomes and resource allocation in neonatal care.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the key differences between epicranial subaponeurotic hemorrhage and cephalohematoma?

Epicranial subaponeurotic hemorrhage occurs beneath the aponeurosis and can cross suture lines, while cephalohematoma is confined to the periosteum and does not cross suture lines. Accurate documentation is essential for proper coding.