Traum hemor left cerebrum with LOC status unknown, sequela

This code signifies a past traumatic bleeding event within the left cerebral hemisphere, where the patient experienced an unknown duration of unconsciousness. The "sequela" designation indicates that this code is used to report residual effects or complications arising from the initial injury, rather than the acute injury itself.

This code is appropriate when a patient presents with ongoing neurological deficits or complications directly attributable to a previously sustained traumatic left cerebral hemorrhage with an unrecorded loss of consciousness. Documentation should clearly link the current condition to the past head injury and specify the left cerebrum as the affected area.

• Always ensure the documentation explicitly states "sequela" or describes a chronic condition resulting from the past injury.
• Do not use this code for the initial acute injury; a different code from the S06.35- series would be used for the acute event.
• Verify laterality (left cerebrum) and the presence of loss of consciousness (even if status unknown) are clearly documented.