Traum hemor cereb, w/o loss of consciousness, init

This code signifies bleeding within the cerebrum due to trauma, where the specific location of the hemorrhage is not documented. The patient did not experience any loss of consciousness as a result of this injury. This represents the initial phase of treatment for the cerebral hemorrhage.

Apply this code when documentation confirms a traumatic cerebral hemorrhage without specifying the exact lobe or area, and explicitly states the patient remained conscious. This is appropriate for the initial hospital visit or encounter for active treatment of the injury. Supporting documentation includes imaging reports (e.g., CT scan, MRI) confirming the hemorrhage and physician notes detailing the mechanism of injury and mental status.

• Ensure documentation explicitly states "without loss of consciousness" to use this specific code; otherwise, a different code indicating altered consciousness or unspecified consciousness should be selected.
• Verify that the encounter is indeed the "initial encounter" for active treatment of the injury. Subsequent care would require a different encounter character.
• Distinguish from non-traumatic cerebral hemorrhages (e.g., spontaneous, hypertensive), which are coded differently.