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

This code describes the long-term effects or complications arising from a past traumatic injury to the brainstem, specifically involving bruising, tearing, or bleeding, where the patient did not lose consciousness at the time of the initial injury. It signifies that the acute phase of the injury has passed, and the patient is now experiencing residual symptoms or conditions directly attributable to that brainstem trauma.

Use this code for patients presenting with chronic neurological deficits, functional impairments, or other lasting sequelae directly linked to a previously sustained brainstem contusion, laceration, or hemorrhage without initial loss of consciousness. Documentation must clearly state the causal relationship between the past brainstem injury and the current condition, and indicate that the acute injury has resolved.

• Always sequence the sequela code first, followed by codes for the specific residual conditions or symptoms.
• Ensure documentation explicitly states "sequela" or "late effect" of the brainstem injury.
• Do not use this code for acute brainstem injuries; those require codes from the S06.38- category without the "S" seventh character.