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

This code describes a long-term effect or complication resulting from a cerebral injury that involved both bruising and tearing of brain tissue. The initial injury was characterized by a brief period of unconsciousness, lasting no more than 30 minutes. This code is used when the patient is presenting for care related to the residual effects of that past trauma.

Apply this code when a patient is seen for sequelae (e.g., cognitive deficits, post-traumatic epilepsy, chronic headaches) directly attributable to a cerebral contusion and laceration with a documented loss of consciousness of 30 minutes or less. The medical record must clearly indicate that the current condition is a residual effect of a previous brain injury, not an acute event.

• This "S" code indicates a sequela and should be used for complications or conditions arising as a direct result of the initial injury, after the acute phase has passed.
• Do not use this code for the initial acute injury; instead, use the appropriate acute injury code (e.g., S06.331A for initial encounter).
• Always code the specific manifestation of the sequela first, followed by this sequela code to indicate the underlying cause.