Contus/lac/hem brainstem w LOC of 30 minutes or less, subs

This code signifies a traumatic injury to the brainstem, specifically involving bruising, tearing, or bleeding, that resulted in a brief period of unconsciousness (30 minutes or less). This particular code is used for encounters following the initial treatment of the injury.

Apply this code for follow-up visits, rehabilitation sessions, or subsequent hospitalizations for a patient previously diagnosed and treated for a brainstem contusion, laceration, or hemorrhage with brief loss of consciousness. Documentation should clearly indicate the injury as a brainstem trauma, specify the nature of the injury (contusion, laceration, or hemorrhage), confirm loss of consciousness of 30 minutes or less, and denote that this is not the initial encounter for the injury.

• Ensure the "D" seventh character is appropriate for a subsequent encounter; do not use for initial treatment or sequelae.
• Verify documentation explicitly states the duration of loss of consciousness was 30 minutes or less.
• Distinguish from other intracranial injuries (e.g., cerebral contusion) and ensure the brainstem is the documented site of injury.