Contus/lac right cerebrum with LOC status unknown, sequela

This code signifies a past injury to the right cerebral hemisphere involving both bruising (contusion) and tearing (laceration) of the brain tissue, which was initially associated with an unknown duration of loss of consciousness. The "sequela" designation indicates that this code is used to report residual effects or late complications stemming from this prior traumatic brain injury.

Use this code when documenting a patient presenting with long-term neurological deficits or complications directly attributable to a previous contusion and laceration of the right cerebrum, where the initial loss of consciousness duration was not specified. Documentation should clearly link the current symptoms or conditions to the historical brain injury.

• Always sequence this sequela code after the code(s) for the specific residual condition(s) being treated.
• Ensure documentation explicitly states "sequela" or clearly indicates a late effect of the specified brain injury.
• Distinguish from acute injury codes; this code is for chronic or residual effects, not the initial injury.