Contus/lac/hem brainstem w LOC >24 hr w ret consc lev, init

This code signifies a severe traumatic brain injury involving contusion, laceration, and hemorrhage specifically affecting the brainstem. The patient experienced a prolonged period of unconsciousness, exceeding 24 hours, but ultimately regained their baseline level of consciousness.

Apply this code for initial encounters when documentation clearly indicates brainstem trauma with both contusion/laceration/hemorrhage and loss of consciousness lasting over 24 hours, followed by a return to the patient's pre-injury conscious state. This is typically seen in acute trauma cases where the patient is first presenting for treatment.

• Ensure documentation specifies brainstem involvement and differentiates it from other brain regions.
• Verify the duration of unconsciousness (greater than 24 hours) and the return to pre-existing conscious level.
• This code is for the "initial encounter" for the injury; subsequent care would require a different seventh character.