Contus/lac cereb, with LOC status unknown, sequela

This code signifies a past injury to the cerebrum involving both bruising (contusion) and tearing (laceration), where the specific details of the loss of consciousness at the time of the original injury are unknown. It indicates that the patient is currently experiencing a residual effect or complication stemming from this previous cerebral trauma.

Apply this code when documentation clearly indicates a sequela (late effect) of an unspecified cerebral contusion and laceration. This is appropriate when the initial injury occurred in the past, and the patient is now being treated for a chronic or persistent condition directly attributable to that trauma, but the original loss of consciousness status was not documented or is unknown.

• Ensure the documentation explicitly states a "sequela" or "late effect" of the cerebral injury.
• Do not use this code for acute injuries; it is specifically for the long-term consequences.
• Always code the specific manifestation of the sequela first, followed by this code to indicate the underlying cause.