Contus/lac/hem brainstem w/o loss of consciousness, init

This code signifies a traumatic injury to the brainstem characterized by bruising, tearing, or bleeding, without any period of unconsciousness. It indicates direct damage to this critical part of the brain, which controls vital functions.

Apply this code for patients presenting with documented brainstem contusion, laceration, or hemorrhage following trauma, who remained conscious throughout the event and subsequent evaluation. Documentation must explicitly state the brainstem as the affected area and confirm the absence of loss of consciousness.

• Ensure documentation specifies "brainstem" and explicitly denies "loss of consciousness."
• Verify the "initial encounter" designation; subsequent care would use a different seventh character.
• Differentiate from other intracranial injuries; this code is specific to brainstem trauma.