Contus/lac r cereb w LOC of 30 minutes or less, sequela

This code signifies a past injury to the right cerebral hemisphere, characterized by both bruising (contusion) and tearing (laceration) of the brain tissue, which initially resulted in a brief period of unconsciousness lasting 30 minutes or less. The "S" suffix indicates that this code is being used to report a sequela, meaning a late effect or complication of the original injury, not the acute injury itself.

Use this code when documenting a patient presenting with a current condition or symptom that is a direct consequence of a previously sustained right cerebral contusion and laceration with brief loss of consciousness. The medical record must clearly link the current presentation to the old brain injury. This code is appropriate when the acute phase of the injury has passed, and the patient is now experiencing residual effects.

• Requires thorough documentation linking the current condition to the old brain injury.
• Always sequence this code after the code(s) for the specific sequela being treated (e.g., cognitive deficits, epilepsy).
• Do not use for the initial acute injury; that would require an acute injury code without the "S" suffix.