Traum hemor right cerebrum with LOC status unknown, subs

This code signifies a traumatic bleeding event within the right cerebral hemisphere, where the patient's level of consciousness at the time of injury is not documented. The "D" seventh character indicates that this is a subsequent encounter for care of the injury, meaning the patient is receiving routine follow-up care during the healing or recovery phase.

Apply this code for patients presenting for follow-up care of a previously diagnosed traumatic right cerebral hemorrhage where the initial loss of consciousness status was not recorded. Documentation should clearly state a traumatic etiology, hemorrhage in the right cerebrum, and indicate a subsequent encounter for the injury.

• Ensure documentation specifies "right cerebrum" and a traumatic cause; otherwise, consider unspecified or other cerebral hemorrhage codes.
• The "D" seventh character is crucial for subsequent encounters; use "A" for initial encounters and "S" for sequelae.
• Always code any associated external cause of injury (e.g., fall, motor vehicle accident) with an appropriate external cause code.