Unsp focal TBI w/o loss of consciousness, sequela

This code signifies the long-term effects or complications arising from a localized head injury that did not involve a period of unconsciousness at the time of the initial trauma. It indicates that the specific nature of the focal brain injury is not documented.

Apply this code when documenting residual symptoms or conditions directly attributable to a past, unspecified focal traumatic brain injury without loss of consciousness. Documentation should clearly link the current condition to the previous head trauma and specify that it is a sequela.

• Ensure documentation explicitly states "sequela" or "late effect" of the prior injury.
• Do not use for acute injuries; this code is exclusively for chronic or residual conditions.
• Always code the specific sequela (e.g., cognitive deficits, headaches) first, followed by this code as a secondary diagnosis.