F25.0 - Schizoaffective disorder, bipolar type

Clinical Definition

A laceration of the cerebellum with loss of consciousness of 31-59 minutes duration, initial encounter.

Documentation Requirements

• Anatomical Location: Must specify cerebellum as site

• Level of Consciousness: Must document exact duration (31-59 minutes)

• Initial vs Subsequent: Document as initial encounter

• Cause of Injury: External cause must be documented

• Glasgow Coma Scale: Record at time of injury and during care

• Associated Injuries: Note any concurrent TBI or other trauma

• Loss of Consciousness (LOC):

  • Exact start time of LOC

  • Exact end time of LOC

  • Any fluctuations in consciousness

Common Synonyms

• Brain tear

• Cerebellar injury

• Cut in back of brain

• Brain laceration

• Balance center injury

Coding Conflicts

Excludes1:

• Concussion with same LOC duration

• Crushing injury of cerebellum

• Diffuse brain injury with same LOC duration

Scribing.io Automation

Our AI scribe automatically:

• Timestamps LOC onset and resolution

• Calculates exact LOC duration

• Flags Glasgow Coma Scale entries

• Links external cause documentation

• Creates timeline of consciousness changes

• Auto-suggests complete ICD-10 code based on documented LOC duration

• Identifies missing elements needed for full code assignment

Be sure to clearly document all elements as listed above to ensure accurate coding and appropriate reimbursement.