Contus/lac/hem crblm with LOC status unknown, sequela

This code signifies a past injury to the cerebellum involving bruising, tearing, and bleeding, where the patient experienced an unknown duration of unconsciousness at the time of the original injury. It specifically indicates that the patient is now presenting with a sequela, or a residual effect, from this prior cerebellar trauma.

Apply this code when a patient presents with ongoing neurological deficits or symptoms directly attributable to a previously sustained cerebellar contusion, laceration, and hemorrhage that involved an unspecifiable period of unconsciousness. Documentation should clearly link the current symptoms to the historical brain injury and confirm the "sequela" status.

• Requires a seventh character "S" to denote sequela; do not use for the initial encounter or subsequent active treatment.
• Ensure documentation specifies the cerebellar location of the injury and the presence of contusion, laceration, and hemorrhage.
• Always sequence this code after the code for the specific sequela (e.g., ataxia, cognitive deficits) that the patient is currently experiencing.