Unsp focal TBI w LOC >24 hr w/o ret consc w surv, sequela

This code signifies a long-term consequence (sequela) of a focal traumatic brain injury where the patient experienced a loss of consciousness exceeding 24 hours and has not regained their pre-injury level of consciousness. It indicates a persistent neurological deficit resulting from the initial trauma, with the patient having survived the acute injury phase.

Use this code for encounters where a patient is being treated for the chronic effects of a focal TBI that involved a prolonged coma (LOC > 24 hours) and permanent cognitive or neurological impairment. Documentation must clearly state the focal nature of the injury, the duration of unconsciousness, and the ongoing sequelae preventing a return to baseline consciousness.

• This "S" code is for sequela and should be used for subsequent encounters after the initial injury has healed.
• Ensure documentation explicitly states "loss of consciousness greater than 24 hours" and "without return to pre-existing conscious level."
• Do not confuse with codes for acute TBI or TBI with shorter durations of unconsciousness or full recovery.