Contus/lac/hem crblm w/o loss of consciousness, sequela

This code signifies a past injury to the cerebellum, characterized by bruising, tearing, or bleeding, which did not result in a loss of consciousness at the time of the initial trauma. It indicates that the patient is now experiencing a residual effect or complication directly attributable to this specific cerebellar injury.

Apply this code when documentation clearly states a sequela (e.g., persistent ataxia, balance issues, cognitive deficits) resulting from a previously sustained contusion, laceration, or hemorrhage of the cerebellum without loss of consciousness. The "S" seventh character indicates that the patient is being seen for the late effects of the injury, not the initial acute event.

• Always use an additional code to specify the nature of the sequela being treated (e.g., R27.0 for ataxia, R41.89 for other specified cognitive deficits).
• Do not use this code for the initial acute injury; instead, use the appropriate S06.37- code without the "S" seventh character.
• Ensure documentation explicitly links the current condition to the past cerebellar injury and confirms the absence of loss of consciousness during the initial event.