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

This code signifies a diffuse traumatic brain injury (TBI) where the patient experienced a loss of consciousness (LOC) lasting between 31 and 59 minutes. "Diffuse" indicates widespread brain injury, rather than a localized lesion. The "sequela" seventh character indicates that this code is used for conditions that are residual effects or complications of the initial injury, occurring after the acute phase has passed.

Use this code when documenting the long-term effects or complications arising from a diffuse TBI that initially presented with a LOC between 31 and 59 minutes. This applies to follow-up encounters for conditions such as post-concussion syndrome, cognitive deficits, or neurological impairments directly attributable to the past TBI. Documentation must clearly state the diffuse nature of the original injury, the specific duration of LOC, and that the current condition is a sequela.

• Ensure the medical record explicitly states the diffuse nature of the original TBI and the exact duration of LOC (31-59 minutes) for accurate code assignment.
• The "S" seventh character is crucial and indicates a sequela; do not use this code for the initial acute injury or subsequent acute exacerbations.
• Always sequence this sequela code first, followed by codes for the specific residual conditions (e.g., cognitive deficits, headaches, epilepsy).