Traum hemor right cerebrum w/o loss of consciousness, subs

This code signifies a brain bleed within the right cerebral hemisphere caused by trauma, where the patient did not lose consciousness at the time of injury. It specifically indicates that the patient is receiving follow-up care for this previously diagnosed condition.

Apply this code for subsequent encounters when a patient is being treated for the ongoing effects or recovery from a traumatic right cerebral hemorrhage, and the initial injury did not involve loss of consciousness. Documentation should clearly state the right cerebrum as the location of the hemorrhage, its traumatic origin, and the absence of loss of consciousness, along with an indication of follow-up care.

• Ensure documentation specifies "subsequent encounter" for ongoing treatment or recovery.
• Verify the laterality (right cerebrum) and absence of loss of consciousness at the time of injury.
• Do not use for initial encounters or if loss of consciousness was documented.