Contus/lac cereb, w LOC of unsp duration, init

This code signifies a traumatic brain injury involving bruising and tearing of the cerebral tissue, where the duration of the associated loss of consciousness is not documented. It indicates an initial presentation for this specific type of cerebral injury.

Apply this code when medical records clearly state a cerebral contusion and laceration, accompanied by loss of consciousness, but the exact duration of unconsciousness is not specified. This code is appropriate for the patient's first encounter for treatment of this injury. Documentation should support both the contusion/laceration and the presence of loss of consciousness.

• Do not use this code if the duration of loss of consciousness is documented; instead, select a more specific code from the S06.33 category.
• Ensure documentation explicitly states both "contusion" and "laceration" of the cerebrum.
• This "initial encounter" code is only for the period when the patient is receiving active treatment for the injury.