Traum hemor cereb, with LOC status unknown, sequela

This code signifies a past cerebral hemorrhage resulting from trauma, where the specific details of the hemorrhage (e.g., intracerebral, subdural) are not documented. It also indicates that the patient's consciousness status at the time of the original injury is unknown, and the current encounter is for a sequela of that prior traumatic event.

Apply this code when a patient presents with a long-term complication or residual effect directly attributable to an old, unspecified traumatic cerebral hemorrhage. Documentation must clearly link the current condition to the past traumatic brain injury and explicitly state that the original loss of consciousness status is undetermined.

• This "S" code is for sequelae; use a "T" code for initial or subsequent encounters for the acute injury.
• Always sequence this sequela code after the code(s) describing the specific residual condition(s) being treated.
• Ensure documentation explicitly states "sequela" or "late effect" of a traumatic cerebral hemorrhage and that the original loss of consciousness status is not known.