F90.0 - Attention-deficit hyperactivity disorder, predominantly inattentive type

Clinical Definition

A contusion (bruise) of the sacral region occurs when blood vessels under the skin are damaged from blunt force trauma to the lower back/tailbone area, causing blood to leak into surrounding tissues. This creates visible discoloration and swelling.

Documentation Requirements

• Location: Must specify "sacral region"

• Acuity:

  • Initial encounter

  • Subsequent encounter

  • Sequela

• Severity: Document any associated complications

• Cause: Document external cause (fall, direct impact, etc.)

• Timing: When injury occurred

• Associated symptoms: Pain level, mobility limitations

Common Synonyms

• Tailbone bruise

• Lower back bruise

• Coccyx contusion

• Sacrum bruise

Coding Conflicts

• Excludes1: Open wound of sacral region

• Excludes2: Multiple contusions affecting other body regions

Scribing.io Automation

The AI scribe automatically identifies key documentation elements:

• Detects anatomical terms ("sacral", "coccyx", "tailbone")

• Tags injury mechanism descriptions

• Flags encounter type keywords

• Captures severity descriptors

• Links associated symptoms and findings

For accurate coding, ensure your dictation includes clear statements about location and encounter type (e.g., "Patient presents with initial sacral contusion after a fall").