Concussion without loss of consciousness, sequela

This code signifies the long-term effects or complications arising from a concussion where the patient did not experience a loss of consciousness at the time of the initial injury. These sequelae can include persistent headaches, cognitive deficits, dizziness, or emotional disturbances that manifest after the acute phase of the concussion has passed.

Apply this code when documenting and billing for conditions directly attributable to a past concussion without loss of consciousness, after the initial injury has healed. Documentation should clearly link the current symptoms or conditions to the previous concussion and indicate that these are residual effects, not acute symptoms.

• Always sequence this code after the code for the specific sequela (e.g., G44.3 for post-traumatic headache).
• Ensure the medical record explicitly states "sequela of concussion" or similar language to support the use of this code.
• Do not use this code for acute concussion symptoms; those are coded with the initial injury codes.