Diffuse TBI w LOC of 1-5 hrs 59 min, sequela

This code signifies a widespread traumatic brain injury, not localized to a specific area, that resulted in a loss of consciousness lasting between one hour and five hours and fifty-nine minutes. The "S" at the end indicates that this code is for the sequela, meaning it's used to report conditions that are residual effects or complications of the initial injury.

This code is appropriate when documenting the long-term effects or complications arising from a diffuse traumatic brain injury where the initial loss of consciousness fell within the specified timeframe. Documentation should clearly state the diffuse nature of the injury, the duration of the initial loss of consciousness, and the current sequela being treated.

• Ensure the medical record explicitly states "diffuse" TBI and the exact duration of loss of consciousness to support this specific code.
• This "S" code is always a secondary diagnosis, following the code for the specific sequela (e.g., cognitive deficits, post-concussion syndrome).
• Do not use this code for initial encounters or active treatment of the acute injury; it is strictly for residual conditions.