Diffuse TBI w loss of consciousness of 31-59 min, subs

This code signifies a widespread brain injury resulting from trauma, where the patient experienced a loss of consciousness lasting between 31 and 59 minutes. This specific code is used when the patient is receiving follow-up care for this injury, after the initial treatment phase.

Apply this code for patients presenting for ongoing management, rehabilitation, or follow-up appointments related to a diffuse traumatic brain injury with a documented loss of consciousness between 31 and 59 minutes. Documentation should clearly state the duration of unconsciousness and indicate that this is not the initial encounter for the injury.

• Ensure the medical record explicitly states "diffuse" traumatic brain injury and the exact duration of loss of consciousness.
• The 7th character "D" is crucial and indicates a subsequent encounter; do not use "A" (initial) or "S" (sequela) for this scenario.
• Always code any associated neurological deficits or sequelae of the TBI separately.