Traum hemor r cereb w LOC >24 hr w/o ret consc w surv, init

This code signifies a severe traumatic brain injury involving bleeding within the right cerebral hemisphere, resulting in a prolonged coma or vegetative state exceeding 24 hours, from which the patient has not recovered to their baseline neurological function. This indicates a significant and lasting neurological deficit due to the injury.

This code is appropriate for the initial encounter of a patient presenting with a traumatic right cerebral hemorrhage and documented loss of consciousness lasting more than 24 hours, with persistent neurological impairment. Documentation must clearly state the duration of unconsciousness and the lack of return to pre-injury conscious level.

• Ensure documentation specifies the right cerebrum and traumatic etiology.
• Verify the duration of loss of consciousness is explicitly stated as greater than 24 hours and that the patient has not returned to their pre-existing conscious level.
• This code is for the "initial encounter" only; subsequent encounters would use a different seventh character.