Traum subdr hem w/o loss of consciousness, sequela

This code signifies a long-term effect or complication arising from a traumatic subdural hemorrhage where the patient did not experience a loss of consciousness at the time of the initial injury. It indicates that the acute phase of the hemorrhage has passed, and the patient is now presenting with residual symptoms or conditions directly attributable to that past injury.

Use this code when documenting a patient's current condition that is a direct consequence of a previously sustained traumatic subdural hemorrhage without loss of consciousness. This applies to follow-up encounters for chronic neurological deficits, cognitive impairments, or other persistent issues stemming from the original subdural bleed. Documentation should clearly link the current sequela to the past traumatic subdural hemorrhage.

• Always sequence the sequela code first, followed by codes for the specific residual conditions (e.g., chronic headache, cognitive deficit).
• Do not use this code for the initial acute injury; it is exclusively for late effects.
• Ensure documentation explicitly states the "sequela" or "late effect" of the prior traumatic subdural hemorrhage.