Contus/lac l cereb w LOC >24 hr w ret consc lev, sequela

This code signifies a chronic or late effect resulting from a severe traumatic brain injury involving both bruising and tearing of the left cerebral hemisphere. The initial injury caused a prolonged loss of consciousness exceeding 24 hours, from which the patient eventually recovered to their baseline mental status.

Apply this code when documenting a sequela (late effect) of a past traumatic brain injury to the left cerebrum. The patient's medical record must clearly indicate a history of a contusion and laceration to the left cerebrum, an initial loss of consciousness lasting over 24 hours, and a subsequent return to their pre-injury conscious level.

• This code is for the sequela of the injury, not the acute event.
• Ensure documentation specifies "left cerebrum" and "loss of consciousness greater than 24 hours with return to pre-existing conscious level."
• Do not use this code for acute injuries or if the patient did not return to their pre-existing conscious level.