Contus/lac/hem brainstem w LOC of 31-59 min, sequela

This code signifies a past injury to the brainstem characterized by bruising, tearing, and bleeding, which resulted in a loss of consciousness lasting between 31 and 59 minutes. It indicates that the patient is now experiencing a long-term consequence or complication stemming from this specific brain injury.

Use this code when documenting a patient's current condition that is a direct result of a previously sustained brainstem injury with the specified duration of loss of consciousness. Documentation must clearly link the current sequela to the historical brainstem trauma and confirm the original loss of consciousness duration. This code is appropriate for follow-up encounters where the acute injury has resolved, but residual effects persist.

• Always assign a sequela code (S06.382S) as a secondary diagnosis, following the code for the specific sequela being treated.
• Ensure documentation explicitly states the duration of loss of consciousness (31-59 minutes) for the initial injury to justify this specific code.
• Do not use this code for the initial acute injury; it is reserved for the long-term effects or complications.