Traum hemor cereb, w/o loss of consciousness, sequela

This code signifies a long-term effect or complication arising from an unspecified traumatic hemorrhage within the cerebrum, where the patient did not experience a loss of consciousness at the time of the initial injury. It indicates that the acute phase of the cerebral bleeding has passed, and the patient is now experiencing residual symptoms or conditions directly attributable to that past trauma.

Use this code when documenting a patient presenting with sequelae (e.g., cognitive deficits, motor weakness, epilepsy) directly linked to a prior traumatic cerebral hemorrhage without loss of consciousness. The medical record must clearly state the causal relationship between the past trauma and the current condition, and specify that the initial injury did not involve a loss of consciousness.

• Ensure documentation explicitly links the current condition to a past traumatic cerebral hemorrhage.
• Verify that the original injury did not involve any loss of consciousness; otherwise, a different code for sequelae of hemorrhage with LOC would be appropriate.
• Always sequence this sequela code first, followed by codes for the specific residual conditions or symptoms being treated.