Late effect of intracranial injury without mention of skull fracture

This code signifies a health problem that developed as a long-term consequence of a past head injury, specifically one that did not involve a skull fracture. These late effects can manifest months or years after the initial trauma, impacting neurological, cognitive, or psychological functions.

Apply this code when documentation clearly indicates a current condition is a sequela of a previous intracranial injury, and the original injury did not involve a skull fracture. Examples include post-concussive syndrome, chronic headaches, or cognitive deficits directly attributed to a past non-fracture head trauma. The patient's medical history must confirm the prior intracranial injury and the absence of a skull fracture.

• Always code the specific manifestation of the late effect first, followed by this code to indicate its etiology.
• Ensure documentation explicitly states the absence of a skull fracture with the original intracranial injury; otherwise, a different late effect code may be more appropriate.
• Distinguish from acute intracranial injuries; this code is exclusively for residual conditions occurring after the acute phase has passed.