Contus/lac cereb, w/o loss of consciousness, init

This code signifies a direct injury to the brain tissue itself, characterized by bruising (contusion) and/or tearing (laceration) of the cerebrum. The patient experienced this cerebral injury without any period of unconsciousness. This code is specifically for the initial treatment or evaluation of this injury.

Use this code for patients presenting with documented cerebral contusion or laceration following trauma, where the medical record explicitly states no loss of consciousness occurred. This code is appropriate for the first encounter for this specific injury, such as in the emergency department or during initial hospitalization. Documentation should clearly specify the nature of the cerebral injury and the absence of altered mental status beyond the immediate impact.

• Ensure documentation explicitly states "without loss of consciousness" to differentiate from codes indicating altered mental status.
• Verify this is indeed the "initial encounter" for this specific injury; subsequent care would use a different seventh character.
• Do not confuse with codes for concussion (S06.0X0A) or other intracranial injuries without direct cerebral tissue damage.