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

This code signifies a long-term effect or complication arising from a past cerebral contusion or laceration, where the initial injury did not involve a loss of consciousness. It indicates that the patient is experiencing residual symptoms or conditions directly attributable to that prior brain trauma.

This code is appropriate when documenting a sequela (e.g., cognitive deficits, persistent headaches, neurological impairment) from a previously sustained cerebral contusion or laceration without loss of consciousness. Documentation must clearly link the current condition to the old brain injury and specify that the original injury did not involve unconsciousness.

• Always sequence the sequela code first, followed by codes for the specific residual conditions or symptoms.
• Ensure documentation explicitly states "sequela" or "late effect" and confirms the absence of loss of consciousness during the initial injury.
• Do not use this code for acute injuries; it is exclusively for chronic or residual conditions.