S06.376A
ICD-10-CMContusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
This code signifies a severe traumatic brain injury involving the cerebellum, characterized by a contusion, laceration, and hemorrhage. The patient experienced a prolonged coma exceeding 24 hours, and upon regaining some consciousness, did not return to their baseline neurological status. This code specifically applies to the initial treatment phase of such an injury where the patient survived.
Apply this code for patients presenting with documented cerebellar trauma, including bruising, tearing, and bleeding, who have a Glasgow Coma Scale (GCS) score indicating a loss of consciousness for more than 24 hours. Documentation must explicitly state that the patient's conscious level did not return to pre-injury baseline and that this is the first encounter for this specific injury.
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