Concussion with LOC status unknown, initial encounter

This code signifies a concussion where the patient's level of consciousness immediately following the injury is not documented or is unclear. It indicates a traumatic brain injury (TBI) of mild severity, characterized by a temporary disturbance of brain function without structural damage. This code is used for the initial assessment and treatment of the injury.

This code is appropriate when a patient presents with symptoms of a concussion (e.g., headache, dizziness, confusion) following head trauma, but the medical record does not specify whether there was a loss of consciousness or the duration of any such loss. Documentation should clearly indicate a concussion diagnosis and the "initial encounter" for treatment of this specific injury.

• Do not use this code if the documentation clearly states no loss of consciousness or a specific duration of loss of consciousness; instead, select a more specific S06.0X_ code.
• Always sequence this code as the primary diagnosis when it is the reason for the encounter.
• Ensure the documentation supports the "initial encounter" designation, meaning the patient is receiving active treatment for the injury.