Contus/lac/hem brnst w LOC of 30 minutes or less, sequela

This code describes the long-term effects or complications arising from a brainstem injury that involved a contusion, laceration, or hemorrhage, and resulted in a brief loss of consciousness (30 minutes or less) at the time of the initial injury. It signifies that the acute phase of the injury 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's current condition that is a direct consequence of a previously sustained brainstem injury with the specified characteristics. This applies to follow-up encounters for ongoing management of neurological deficits, cognitive impairments, or other sequelae. Documentation should clearly link the current symptoms to the past brainstem trauma and specify the nature of the initial injury and duration of unconsciousness.

• Always assign a sequela code when the patient is seen for residual effects of an old injury, not the acute injury itself.
• Ensure documentation explicitly states "sequela" or indicates that the current condition is a late effect of the specified brainstem injury.
• Do not use this code for the initial acute injury; instead, use the appropriate acute injury code with the 7th character for initial encounter.