Epidural hemorrhage with LOC status unknown, sequela

This code signifies a chronic or residual condition resulting from a past epidural hemorrhage that was accompanied by a period of unconsciousness. It indicates that the specific duration or nature of the loss of consciousness is not documented. This code is used to report the long-term effects or complications of such an injury, rather than the acute event itself.

Apply this code when a patient presents with a sequela (e.g., cognitive deficits, neurological impairment, chronic headaches) directly attributable to a previously sustained epidural hemorrhage with undocumented loss of consciousness. Documentation should clearly link the current condition to the past head injury and specify that it is a residual effect. This code is appropriate for follow-up visits addressing these long-term consequences.

• Always sequence this sequela code after the code describing the specific residual condition being treated.
• Do not use this code for the acute phase of the epidural hemorrhage; use codes from the S06.4- series for the initial injury.
• Ensure documentation explicitly states "sequela" or describes a chronic condition resulting from the past injury, and that the loss of consciousness status is truly unknown.