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

This code describes a brain injury involving both bruising (contusion) and tearing (laceration) of the cerebrum, the largest part of the brain, without any period of unconsciousness. It indicates that the patient is receiving follow-up care for this specific injury.

Use this code for subsequent encounters when a patient is being treated for a previously diagnosed cerebral contusion and laceration, and there was no loss of consciousness at the time of the injury. Documentation should clearly state the nature of the cerebral injury (contusion and laceration), the absence of loss of consciousness, and that the encounter is for follow-up care, healing, or management of complications.

• Ensure documentation specifies both "contusion" and "laceration" of the cerebrum; if only one is present, a different code is required.
• The 7th character "D" indicates a subsequent encounter, meaning the patient is receiving routine care during the healing or recovery phase.
• Verify that there was no loss of consciousness associated with the initial injury; if loss of consciousness occurred, a different code with a different 6th character is appropriate.