Contus/lac/hem brnst w LOC >24 hr w ret consc lev, sequela

This code signifies a past traumatic injury to the brainstem, specifically involving contusion, laceration, or hemorrhage, that resulted in a prolonged loss of consciousness exceeding 24 hours. Crucially, the patient subsequently recovered to their baseline level of consciousness. This code indicates a sequela, meaning it describes a residual condition or late effect of the initial injury.

Use this code when documenting the long-term effects of a brainstem injury where the acute event has passed, and the patient's consciousness has returned to their pre-injury state. Documentation must clearly state the nature of the brainstem injury (contusion, laceration, hemorrhage), the duration of unconsciousness (greater than 24 hours), and the return to pre-existing conscious level.

• This "S" seventh character indicates a sequela, meaning it should be used for complications or conditions arising as a direct result of a previous injury, not for the initial acute injury.
• Ensure documentation explicitly states "return to pre-existing conscious level" to differentiate from other loss of consciousness outcomes.
• Do not use this code for the initial encounter of the injury or for subsequent encounters where the patient has not returned to their pre-existing conscious level.