Concussion without loss of consciousness, subs encntr

This code signifies a concussion where the patient did not experience a loss of consciousness, and the encounter is for follow-up care, monitoring, or treatment of the concussion's lingering effects. It indicates that the initial injury has already been addressed, and the patient is now in a recovery or management phase.

Apply this code for patients presenting for follow-up appointments related to a previously diagnosed concussion without loss of consciousness. Documentation should clearly state "subsequent encounter," "follow-up," or indicate ongoing management of the concussion, such as symptom monitoring, cognitive rehabilitation, or return-to-play protocols.

• Ensure documentation explicitly states "subsequent encounter" or similar to differentiate from initial care.
• Do not use this code for the initial diagnosis and treatment of the concussion; refer to the "A" (initial encounter) or "S" (sequela) seventh character.
• Consider co-reporting with codes for specific concussion symptoms (e.g., headache, dizziness) if they are being actively managed during the subsequent encounter.