Traum hemor left cerebrum with LOC status unknown, subs

This code signifies a traumatic bleeding event within the left cerebral hemisphere, where the patient's level of consciousness at the time of injury is not documented. It specifically indicates that this is not the initial encounter for this injury, but rather a follow-up visit for ongoing care or complications.

Apply this code for subsequent encounters when a patient is receiving treatment for a previously diagnosed traumatic left cerebral hemorrhage, and the initial documentation did not specify the presence or duration of loss of consciousness. Documentation should clearly indicate a follow-up visit for this specific injury.

• Ensure the encounter is truly "subsequent" and not the initial treatment for the injury.
• Confirm that the hemorrhage is specifically located in the left cerebrum.
• Verify that the documentation explicitly states "loss of consciousness status unknown" or lacks information regarding LOC at the time of injury.