Contus/lac/hem brainstem with LOC status unknown, subs

This code signifies a traumatic injury to the brainstem, involving bruising, tearing, or bleeding, where the patient's level of consciousness at the time of injury is not documented. This specific code is used for follow-up care after the initial treatment of the brainstem injury.

Apply this code for patients presenting for subsequent care (e.g., rehabilitation, follow-up clinic visits) related to a previously diagnosed brainstem contusion, laceration, or hemorrhage. Documentation should clearly indicate a prior brainstem injury and ongoing management or assessment, without a specified initial loss of consciousness status.

• Ensure documentation specifies "subsequent encounter" for this brainstem injury.
• Do not use this code for the initial encounter; a different seventh character is required.
• Confirm the absence of documented loss of consciousness status at the time of injury to differentiate from codes specifying "with loss of consciousness of 30 minutes or less," "with loss of consciousness of 31 minutes to 59 minutes," etc.