Unsp intracranial injury w/o loss of consciousness, init

This code signifies a head injury affecting the brain or its surrounding structures where the specific type of intracranial injury is not documented. The patient did not experience any loss of consciousness at the time of the injury. This code is used for the initial treatment of such an injury.

Apply this code when documentation indicates a head injury with suspected brain involvement, but the physician has not specified the exact nature of the intracranial injury (e.g., concussion, contusion, hemorrhage). This is appropriate for the first encounter for this specific injury. Supporting documentation would include notes indicating "head injury," "intracranial injury," or "brain injury" without further specificity, and explicitly stating "no loss of consciousness."

• Ensure documentation explicitly states "without loss of consciousness." If loss of consciousness occurred, a different code from the S06 category is required.
• This code is for the "initial encounter." For subsequent care, use a code with the appropriate seventh character (D for subsequent, S for sequela).
• Avoid using this code if a more specific intracranial injury (e.g., S06.0X0A for concussion) is documented. Always code to the highest level of specificity available.