🧬 ICD-10 CM I62.01 — Nontraumatic Acute Subdural Hemorrhage
Billable Code Confirmed
ICD-10 CM I62.01 is a fully billable, 6-character ICD-10-CM code valid for FY2026 (October 1, 2025 - September 30, 2026). The 5th character “0” specifies the subdural space, and the 6th character “1” specifies the acute temporal phase, satisfying full coding specificity requirements. No additional characters are required or available, making this a terminal, submission-ready code.
Non-Billable Parent Codes
I62 — “Other and unspecified nontraumatic intracranial hemorrhage” is a non-billable header code requiring further specification. I62.0 — “Nontraumatic subdural hemorrhage” is a non-billable subcategory code that lacks the required temporal phase specificity (acute/subacute/chronic/unspecified). Both parent codes will trigger an MCE (Medicare Code Editor) edit if submitted on a claim and must never be used in place of I62.01 when the acute phase is clinically documented.
Clinical Context
The “acute” designation in I62.01 refers to a subdural hemorrhage that has occurred within approximately 72 hours of onset, distinguished by hyperdense appearance on non-contrast CT imaging and rapid neurological deterioration. The temporal phase specificity — acute vs. I62.02 (subacute, ~4-21 days) vs. I62.03 (chronic, >21 days) — is a critical CDI opportunity because it directly drives DRG assignment, surgical decision-making documentation, and risk adjustment capture. When clinical documentation states only “subdural hematoma” without a temporal qualifier, a physician query is warranted before defaulting to I62.00 (unspecified).
Code Classification
ICD-10 CM I62.01 is a diagnosis code (ICD-10-CM), not a procedure code. This code classifies the hemorrhage itself as a nontraumatic condition, which excludes any traumatic etiology; when trauma is the documented cause, the appropriate codes fall under S06.5X- (Traumatic subdural hemorrhage) in Chapter 19. Any associated procedures (e.g., burr hole drainage, craniotomy, ICP monitoring) must be captured separately using ICD-10-PCS codes in the inpatient setting.
🔍 Code Description
Nontraumatic acute subdural hemorrhage (I62.01) refers to bleeding into the subdural space — the potential space between the dura mater and the arachnoid mater — that arises from a cause other than external trauma and presents within the acute phase window (generally accepted as within 72 hours of onset). The most common nontraumatic etiologies include coagulopathy (especially anticoagulant therapy with agents such as warfarin or direct oral anticoagulants), rupture of cortical bridging veins due to Spontaneous intracranial hypotension, vascular malformations, dural metastases, and coagulopathy related to thrombocytopenia. The accumulation of blood in the subdural space exerts mass effect on the underlying cortex, potentially causing midline shift, herniation syndromes, and life-threatening neurological deterioration — making this a true medical and surgical emergency in many presentations.
From a coding standpoint, the nontraumatic designation is important and distinct from traumatic subdural hemorrhage (S06.5X-), which belongs to Chapter 19. I62.01 sits within Chapter 9 (Diseases of the Circulatory System, I00-I99), under the Cerebrovascular diseases block (I60-I69), and carries an Excludes1 note that prohibits simultaneous coding with any traumatic intracranial hemorrhage code. A “Use additional code” instruction at the category I62 level directs coders to assign R29.7- (NIHSS score) when documented — this is a frequently missed secondary code that enhances clinical severity capture and supports CDI efforts for appropriate DRG weight, particularly when the NIHSS score is elevated enough to support MCC-level severity arguments. The ICD-9-CM approximate equivalent was 432.1 (Subdural hemorrhage), though the GEM mapping is flagged as approximate only, reflecting the increased specificity of the ICD-10-CM classification.
🌳 Code Tree / Hierarchy
I62 — Other and unspecified nontraumatic intracranial hemorrhage ❌ Non-billable
│
├── I62.0 — Nontraumatic subdural hemorrhage ❌ Non-billable
│ │
│ ├── I62.00 — Nontraumatic subdural hemorrhage, unspecified ✅ Billable
│ ├── I62.01 — Nontraumatic acute subdural hemorrhage ◀ THIS CODE ✅ Billable
│ ├── I62.02 — Nontraumatic subacute subdural hemorrhage ✅ Billable
│ └── I62.03 — Nontraumatic chronic subdural hemorrhage ✅ Billable
│
├── I62.1 — Nontraumatic extradural hemorrhage ✅ Billable
└── I62.9 — Nontraumatic intracranial hemorrhage, unspecified ✅ BillableTemporal Phase Specificity Drives DRG and CDI Value
Selecting I62.01 (acute) over the unspecified I62.00 is not merely a compliance distinction — it directly communicates to the clinical team, quality reviewers, and payers that hemorrhage is in its most hemodynamically unstable phase, supporting medical necessity for ICU-level care, neurosurgical intervention authorization, and appropriate DRG grouping. Payers performing post-payment audits may flag I62.00 as lacking clinical documentation support when the record clearly describes CT findings consistent with acute hyperdense blood.
Tip
Always verify the CT radiology report and neurosurgery/neurology attending notes for explicit language describing the hemorrhage as “acute,” “subacute,” or “chronic” — or imaging descriptors (hyperdense = acute, isodense = subacute, hypodense = chronic). If the attending uses only “subdural hematoma” without a phase qualifier and imaging clearly supports acute phase, this is a prime CDI query opportunity. Do not assign I62.01 based on imaging interpretation alone without physician documentation linkage.
✅ Includes
- Acute nontraumatic intracranial subdural hematoma — The terms “hematoma” and “hemorrhage” are indexed to the same code in this context; both are acceptable clinical documentation triggers for I62.01.
- Non-traumatic hematoma of subdural space of neuraxis — This broader anatomical phrasing maps to the same code per the ICD-10-CM Index to Diseases and Injuries.
- Acute nontraumatic subdural hemorrhage — Direct synonym; any variation of this phrase in documentation, whether from neurology, neurosurgery, or radiology, supports I62.01 assignment.
❌ Excludes
Excludes 1
S06.5X- — Traumatic subdural hemorrhage: This is a hard Excludes 1, meaning I62.01 and any S06.5X- code cannot be coded together on the same claim as they are mutually exclusive by definition. The distinction between traumatic and nontraumatic is determined by the documented etiology — if a fall or head injury is the precipitating event, the S06.5X- series applies, even in patients with concurrent anticoagulation. When trauma and spontaneous hemorrhage co-exist in documentation (e.g., a patient on warfarin who falls), clinical judgment and physician query are essential to establish the primary etiology before code assignment.
S09.8XXA, S09.8XXD, S09.8XXS — Other specified intracranial injuries (traumatic): Similarly excluded when a traumatic mechanism is the documented cause. Coders should not use I62.01 as a “backup” when traumatic codes are the correct primary classification.
Danger
The most common Excludes 1 error with I62.01 is dual-coding with a traumatic subdural code when a patient with spontaneous SDH subsequently falls in the hospital or has a minor head injury history that is incidental. Documentation must clearly support nontraumatic etiology for I62.01 to stand; otherwise, this represents a post-payment audit vulnerability and a potential False Claims Act risk if auditors determine the nontraumatic code was assigned without adequate clinical support.
Excludes 2
ICD-10 CM I69.2 — Sequelae of other nontraumatic intracranial hemorrhage: This Excludes 2 means that when a patient presents with late effects of a prior nontraumatic intracranial hemorrhage (e.g., post-hemorrhagic hemiplegia, cognitive deficits from a prior SDH event), I69.2 and its subcategories may be coded separately and concurrently with I62.01 if the current encounter involves a new, acute hemorrhage in addition to documented residual effects of a prior event. This is clinically relevant in patients with recurrent SDH or those presenting with both a new acute hemorrhage and documented neurological sequelae from a prior bleed.
📋 Clinical Overview
Temporal Phase Distinction: Acute vs. Subacute vs. Chronic SDH
Understanding the temporal classification of subdural hemorrhage is the foundational clinical and coding distinction for this entire subcategory. Radiographic and clinical parameters — not simply time elapsed — ultimately guide whether a hemorrhage is classified as acute, subacute, or chronic, and CT Hounsfield units are the primary imaging discriminator used by radiologists. The following table highlights key differentiators between the three billable temporal phase codes within I62.0-:
| Feature | I62.01 | I62.02 | I62.03 |
|---|---|---|---|
| Temporal Phase | Acute (~0-72 hours) | Subacute (~4-21 days) | Chronic (>21 days) |
| CT Appearance | Hyperdense (bright white on NECT) | Isodense (same density as brain parenchyma) | Hypodense (dark/lucent) |
| Clinical Presentation | Rapid neurological deterioration, altered LOC, herniation risk | Variable — may be subtle, headache, progressive cognitive change | Often insidious; confusion, gait instability, dementia-mimic in elderly |
| Surgical Urgency | Often emergent craniotomy or burr hole evacuation | Semi-elective; surgical decision based on mass effect | Frequently managed with burr hole drainage; MMAE emerging option |
| DRG / Coding Impact | Highest acuity; most likely to carry MCC-qualifying comorbidities | Moderate; MCC/CC still possible depending on comorbidity burden | Lower acuity baseline; MCC/CC capture still critical |
| HCC Capture | Maps to V28 HCC 248 (RAF 0.239 community non-dual aged) | Maps to V28 HCC 248 | Maps to V28 HCC 248 |
Important
CDI teams should alert physicians to document the phase of the hemorrhage explicitly in the H&P, progress notes, and discharge summary rather than relying solely on radiology report language. If only the radiology report supports acute phase but the attending’s documentation is silent on temporal classification, a compliant CDI query is appropriate and protects coding accuracy under audit.
Manifestations & Symptom Burden
- Altered Level of Consciousness / Coma — Ranges from mild confusion to deep coma depending on hematoma volume and rate of accumulation; altered LOC documented as a manifestation is NOT separately coded per sequencing rules (integral to the condition).
- Hemiplegia / Hemiparesis — Contralateral motor deficits may develop due to compression of the underlying cortex or uncal herniation; when documented as a distinct complication or deficit, additional codes from G81.- may apply per physician documentation.
- Elevated Intracranial Pressure (ICP) — Mass effect from hematoma expansion drives ICP elevation; G93.2 (Benign intracranial hypertension) is NOT appropriate here — the ICP elevation is etiologically linked to the hemorrhage.
- Seizures — Post-hemorrhagic seizures are a recognized complication; when documented and treated, assign an additional code from G40.- series per physician linkage documentation.
- Midline Shift — Documented midline shift on imaging reflects severity of mass effect and supports medical necessity for surgical intervention and ICU-level monitoring; document clearly in CDI queries.
Tip
Per ICD-10-CM Official Guidelines Section I.C.6, signs and symptoms that are integral to the cerebrovascular condition (e.g., headache, confusion, focal neuro deficits) are not assigned as separate codes. However, complications not routinely associated — such as pneumonia, DVT, or acute respiratory failure developing during the hospitalization — should be captured and sequenced as additional diagnoses. These secondary diagnoses are your MCC/CC leverage for DRG optimization and must be present on admission (POA) status documented correctly on the UB-04.
💰 HCC Risk Adjustment
| Model | HCC Category | RAF (Community Non-Dual Aged) | RAF (Community PBA) | RAF (Community FBA) | RAF (Institutional) |
|---|---|---|---|---|---|
| CMS-HCC V28 (PY2026) | HCC 248 — Intracranial Hemorrhage | 0.239 | 0.313 | 0.377 | 0.081 |
| CMS-HCC V24 (legacy) | HCC 99 — Intracranial Hemorrhage | ~0.258 | — | — | — |
ICD-10 CM I62.01 maps to CMS-HCC V28 HCC 248 (Intracranial Hemorrhage) with a community non-dual aged RAF coefficient of 0.239 for payment year 2026, representing the 100% phase-in of the V28 model. Because I62.01 describes an acute, not chronic, condition, it does not auto-carry forward in risk adjustment data submissions — it must be documented and coded on an eligible face-to-face encounter within the data collection year. For Medicare Advantage plans, this means that a patient hospitalized for acute SDH in the data collection year must have the diagnosis captured on a qualifying encounter to influence the PY2026 RAF score. The transition from V24 HCC 99 to V28 HCC 248 came with a slight coefficient change, and coders who previously relied on V24 mappings should verify their encoder tools reflect current V28 logic for all intracranial hemorrhage codes.
🏥 MS-DRG Assignment
| Scenario | DRG | Title | CC/MCC Status |
|---|---|---|---|
| I62.01 as PDX, no qualifying OR procedure, with MCC | 064 | Intracranial Hemorrhage or Cerebral Infarction with MCC | MCC present |
| I62.01 as PDX, no qualifying OR procedure, with CC or tPA ≤24h | 065 | Intracranial Hemorrhage or Cerebral Infarction with CC or tPA in 24 Hours | CC present |
| I62.01 as PDX, no qualifying OR procedure, no CC/MCC | 066 | Intracranial Hemorrhage or Cerebral Infarction without CC/MCC | None |
| I62.01 as PDX, intracranial vascular OR procedure, with MCC | 020 | Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage with MCC | MCC present |
| I62.01 as PDX, intracranial vascular OR procedure, with CC | 021 | Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage with CC | CC present |
| I62.01 as PDX, intracranial vascular OR procedure, no CC/MCC | 022 | Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage without CC/MCC | None |
When I62.01 is the principal diagnosis without an intracranial surgical procedure, the case groups to the medical DRG tier (064/065/066) under MDC 01. The single greatest DRG optimization lever is accurate CC/MCC capture — common MCCs in this population include acute respiratory failure (J96.00/J96.01), severe sepsis (A41.9 + R65.20/R65.21), and coma (when separately documented). When a qualifying intracranial vascular procedure (craniotomy = 00C40ZZ, burr hole drainage = 00943ZZ) is performed, the case shifts to the surgical DRG 020/021/022 tier, dramatically impacting reimbursement. Coders must ensure the OR procedure is present and correctly coded in ICD-10-PCS before the surgical DRG can be assigned; failure to capture the procedure or using a non-OR ICD-10-PCS code will result in the case staying in the medical DRG tier.
🔗 Related ICD-10-CM Codes
Nontraumatic Intracranial & Intracerebral Hemorrhage Family
- I62.00 — Nontraumatic subdural hemorrhage, unspecified
- I62.02 — Nontraumatic subacute subdural hemorrhage
- I62.03 — Nontraumatic chronic subdural hemorrhage
- I62.1 — Nontraumatic extradural hemorrhage
- I62.9 — Nontraumatic intracranial hemorrhage, unspecified
- I61.9 — Nontraumatic intracerebral hemorrhage, unspecified
- I60.9 — Nontraumatic subarachnoid hemorrhage, unspecified
Sequelae, Comorbidities & Associated Codes
- I69.2 — Sequelae of other nontraumatic intracranial hemorrhage (Excludes 2 — can code separately)
- R29.7- — NIHSS score (use additional code per I62 category instruction)
- Z79.01 — Long-term (current) use of anticoagulants (frequent etiology-related Z code)
- D68.32 — Hemorrhagic disorder due to extrinsic circulating anticoagulants (if anticoagulant-induced)
- G93.6 — Cerebral edema (when documented as complication)
- S06.5X0A — Traumatic subdural hemorrhage without LOC, initial encounter (excluded — traumatic etiology)
🛠️ Commonly Associated CPT Codes
(Note: CPT codes are used for professional/outpatient fee schedule billing. In the inpatient facility setting, ICD-10-PCS is used for procedure coding. CPT codes listed here reflect professional component billing — e.g., attending neurosurgeon, neurologist.)
- 61314 — Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural: This is the primary CPT code for open surgical evacuation of an acute subdural hematoma via craniotomy. Documentation must support the supratentorial location and open approach. Bilateral procedures may require modifier -50.
- 61315 — Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral: Use when the hemorrhage is intracerebral rather than subdural — not appropriate for I62.01 but a common confusion point when the hematoma extends into brain parenchyma.
- 61108 — Twist drill hole(s) for subdural, epidural, or ventricular puncture: Applied when only burr/twist drill hole drainage is performed rather than a full craniotomy; supports less invasive approach documentation.
- 99291-99292 — Critical care services (first 30-74 minutes; each additional 30 minutes): Commonly billed by attending or intensivist for critical care management of acute SDH; documentation must explicitly state the critical care time and the critical condition. Not separately billable if bundled with a major surgical procedure on the same date by the same provider.
- 70450 / 70460 / 70470 — CT head without contrast / with contrast / with and without contrast: CT imaging is central to diagnosis confirmation and temporal classification; CPT 70450 (non-contrast) is the most common initial imaging code and the one most likely to generate the radiologic documentation supporting I62.01 specificity.
NCCI Bundling Considerations
ICD-10-PCS procedure codes for subdural drainage (00943ZZ, 00C40ZZ) must reflect the actual operative approach and root operation as documented; failure to accurately distinguish “drainage” (liquid evacuation) from “extirpation” (removal of solid/clotted matter) is a frequent ICD-10-PCS assignment error that can trigger NCCI-equivalent facility edit flags. In the outpatient/professional arena, CPT 61108 (twist drill hole drainage) and 61314 (open craniotomy) are mutually exclusive on the same date by the same provider — billing both without a valid modifier constitutes a bundling violation.
🔬 ICD-10-PCS Crosswalk
- 00940ZZ — Drainage of Intracranial Subdural Space, Open Approach: Used when the surgeon performs a craniotomy with open drainage of a liquid subdural collection; the root operation is Drainage (taking or letting out fluids) when the evacuated material is predominantly liquid/non-clotted blood.
- 00943ZZ — Drainage of Intracranial Subdural Space, Percutaneous Approach: Applied when only burr hole(s) are made without craniotomy, allowing percutaneous needle or catheter access to drain the subdural collection; this is the most common approach code for acute SDH managed with a single burr hole.
- 00C40ZZ — Extirpation of Matter from Intracranial Subdural Space, Open Approach: Used when the subdural collection is organized/clotted (solid matter) requiring craniotomy for removal; the root operation shifts from Drainage to Extirpation per ICD-10-PCS guidelines when solid matter is the primary substance removed — a frequently queried distinction in coding clinics.
- 00C43ZZ — Extirpation of Matter from Intracranial Subdural Space, Percutaneous Approach: Applied when clotted/organized subdural hematoma is removed via burr hole(s) without full craniotomy; relevant in cases where organized clot is irrigated and extracted percutaneously.
💊 Coding Scenarios and Examples
Scenario 1: Acute SDH in Anticoagulated Patient, Managed Medically
A 74-year-old male on warfarin for atrial fibrillation presents with acute onset headache, confusion, and left-sided weakness. Non-contrast CT head reveals a right-sided hyperdense subdural collection with 6mm midline shift. Neurosurgery evaluates and defers surgical intervention; patient is managed with Kcentra for INR reversal and ICU monitoring. NIHSS documented as 14. Discharge diagnoses: acute nontraumatic subdural hemorrhage, atrial fibrillation, anticoagulant reversal.
Correct Coding:
- PDX: I62.01 — Nontraumatic acute subdural hemorrhage
- I48.91 — Unspecified atrial fibrillation
- Z79.01 — Long-term use of anticoagulants
- D68.32 — Hemorrhagic disorder due to extrinsic circulating anticoagulants
- R29.7- — NIHSS score (specific 7th character based on documented score of 14)
Sequencing: I62.01 is the PDX as the condition chiefly responsible for the admission. Atrial fibrillation and anticoagulant use are sequenced as additional diagnoses providing clinical context. D68.32 captures the coagulopathic mechanism and may serve as a CC, potentially pushing the case from DRG 066 to DRG 065. CDI Note: Query the attending to confirm “acute” phase classification in the discharge summary; confirm NIHSS documentation by the neurologist to capture the R29.7- add-on code.
Scenario 2: Acute SDH with Emergent Craniotomy
A 58-year-old female with no known coagulopathy presents to the ED obtunded after sudden-onset severe headache. MRI and CT confirm a large right-sided acute subdural hematoma with significant midline shift and early uncal herniation. She is taken emergently to the OR for right-sided craniotomy with evacuation of an organized subdural clot. She develops hospital-acquired pneumonia on day 4 requiring broad-spectrum antibiotics.
Correct Coding:
- PDX: I62.01 — Nontraumatic acute subdural hemorrhage
- 00C40ZZ — Extirpation of matter from intracranial subdural space, open approach (craniotomy for organized clot)
- J18.9 — Pneumonia, unspecified organism (hospital-acquired; CC)
- Z87.39 — Personal history of other endocrine, nutritional and metabolic diseases (if applicable)
Sequencing: I62.01 is PDX. The OR procedure 00C40ZZ triggers surgical DRG logic, shifting the case to DRG 020/021/022 (Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage). Hospital-acquired pneumonia as a CC moves the grouping to DRG 021. CDI Note: Confirm the operative report uses language supporting “organized clot” or “solid hematoma” to justify Extirpation root operation over Drainage. If liquid/unclotted blood was primarily evacuated, PCS code shifts to 00940ZZ (Drainage, Open).
Scenario 3: Acute-on-Chronic Subdural Hemorrhage
An 82-year-old male with a known prior right-sided subdural hematoma (treated conservatively 6 weeks ago) presents with acute worsening of confusion and new right pupil dilation. CT reveals a chronic subdural collection with a new hyperdense component superimposed — consistent with acute-on-chronic SDH. Neurosurgery performs emergent right burr hole drainage.
Correct Coding:
- PDX: I62.01 — Nontraumatic acute subdural hemorrhage (acute component drives the current admission and intervention)
- I62.03 — Nontraumatic chronic subdural hemorrhage (underlying chronic component, separately coded per clinical significance)
- 00943ZZ — Drainage of intracranial subdural space, percutaneous approach (burr hole)
Sequencing: I62.01 is sequenced as PDX because the acute hemorrhagic component is what precipitated the admission and required emergent intervention. I62.03 is a secondary diagnosis representing a co-existing chronic condition that is clinically significant per UHDDS guidelines. CDI Note: This is a high-yield CDI scenario — many coders incorrectly default to I62.03 alone or I62.00 (unspecified) in acute-on-chronic presentations. A physician query explicitly asking the attending to document both the acute hemorrhage component and the underlying chronic collection supports dual-code assignment.
⚠️ Coding Pitfalls and Tips
- Pitfall — Defaulting to I62.00 (Unspecified): When CT documentation and clinical notes clearly support an acute presentation (hyperdense blood, rapid deterioration, onset within 72 hours), assigning I62.00 instead of I62.01 is a specificity failure that understates clinical severity, may reduce DRG weight, and misses appropriate HCC capture. Always query when temporal phase is undocumented but clinically inferable.
- Pitfall — Confusing Traumatic vs. Nontraumatic Etiology: Patients on anticoagulants who fall represent the classic gray zone — the fall may be incidental (e.g., the patient fell because of the SDH causing sudden neurological change) or causative. Per Official Guidelines, when both mechanisms are present, physician documentation must clarify the primary etiology. Never assume nontraumatic without documentation support.
- Tip — Always Assign NIHSS (R29.7-): The “Use additional code” instruction at category I62 level directs coders to assign the NIHSS score code when documented. This is a compliance requirement and a CDI opportunity — document the NIHSS in every cerebrovascular encounter.
- Pitfall — ICD-10-PCS Root Operation Error (Drainage vs. Extirpation): For surgical cases, coders must review the operative report to determine if the evacuated material was liquid (→ Drainage) or solid/organized clot (→ Extirpation). This distinction drives the 3rd character of the ICD-10-PCS code and affects claim accuracy. Using the wrong root operation is a common post-payment audit finding.
- Tip — Capture Anticoagulant-Related Secondary Codes: When nontraumatic SDH is precipitated by anticoagulation therapy, assign Z79.01 (long-term anticoagulant use) and D68.32 (hemorrhagic disorder due to extrinsic circulating anticoagulants) as additional diagnoses. D68.32 may qualify as a CC and improve DRG grouping from 066 to 065.
- Pitfall — Missing the Surgical DRG Shift: If an OR-qualifying ICD-10-PCS procedure is performed (craniotomy, burr hole drainage) but the coder fails to code it correctly (e.g., uses a non-OR code or omits it entirely), the case stays in the medical DRG tier (064/065/066) instead of the surgical tier (020/021/022), potentially resulting in significant reimbursement loss for the facility.