Contus/lac right cerebrum w LOC of 31-59 min, sequela

This code signifies a past injury to the right cerebral hemisphere involving both bruising (contusion) and tearing (laceration) of brain tissue, which was initially accompanied by a loss of consciousness lasting between 31 and 59 minutes. The "sequela" designation indicates that this code is used to report residual effects or complications arising from this previous brain injury.

Use this code when a patient presents with ongoing neurological deficits or complications directly attributable to a prior right cerebral contusion and laceration, where the initial injury involved a moderate period of unconsciousness. Documentation must clearly link the current condition to the specified past traumatic brain injury and its initial severity.

• Always ensure documentation specifies the laterality (right cerebrum) and the duration of the initial loss of consciousness.
• This "S" (sequela) code is used for conditions that are residual effects of the original injury, not for the acute injury itself.
• Code any specific neurological sequelae (e.g., hemiparesis, cognitive deficits) in addition to this sequela code.