Contus/lac left cerebrum w/o loss of consciousness, sequela

This code signifies a past injury to the left cerebral hemisphere, specifically a bruise (contusion) and/or a tear (laceration), that did not involve any period of unconsciousness at the time of the initial injury. The "sequela" designation indicates that this code is used to report a current condition or complication that is a residual effect of that original cerebral trauma.

Use this code when a patient presents with a current neurological deficit, cognitive impairment, or other long-term consequence directly attributable to a previously sustained contusion and laceration of the left cerebrum, where the initial injury did not involve loss of consciousness. Documentation must clearly link the current condition to the old cerebral injury and specify the left cerebrum as the affected area.

• Always sequence this sequela code after the code for the specific residual condition being treated (e.g., aphasia, hemiparesis).
• Ensure documentation explicitly states "sequela" or clearly indicates a chronic, residual effect of a past injury.
• Distinguish from acute injuries; this code is for the late effects of the initial trauma.