Concussion without loss of consciousness, initial encounter

This code signifies a mild traumatic brain injury (mTBI) resulting from a direct or indirect blow to the head, characterized by a temporary alteration in mental status without any period of unconsciousness. Symptoms may include headache, dizziness, confusion, and memory issues, but no structural brain damage is typically evident on imaging.

Apply this code for patients presenting with signs and symptoms of a concussion following head trauma, where the medical record explicitly states no loss of consciousness occurred. This code is appropriate for the initial evaluation and treatment of the concussion. Documentation should clearly describe the mechanism of injury and the absence of syncope.

• Ensure documentation explicitly states "without loss of consciousness" to differentiate from other concussion codes.
• Verify this is the patient's first encounter for this specific concussion; subsequent encounters would use a different seventh character.
• Do not confuse with codes for intracranial hemorrhage or other more severe traumatic brain injuries.