Contus/lac right cerebrum w/o loss of consciousness, sequela

This code describes the long-term effects or complications arising from a past contusion and laceration to the right cerebral hemisphere, where the initial injury did not involve a loss of consciousness. It signifies that the acute injury has resolved, but the patient continues to experience residual symptoms or conditions directly attributable to that specific brain trauma.

Use this code when documenting a patient presenting with ongoing neurological deficits, cognitive impairments, or other sequelae directly linked to a previously sustained contusion and laceration of the right cerebrum without loss of consciousness. Documentation must clearly state the causal link between the past injury and the current condition, and indicate that the acute phase of the injury has passed.

• Always sequence the sequela code first, followed by codes for the specific neurological or cognitive deficits.
• Ensure documentation explicitly states "sequela" or "late effect" and links the current condition to the specified past injury.
• Distinguish from acute injuries (codes without the "S" seventh character) and initial encounters for subsequent care.