Personal history of traumatic brain injury

This code signifies a patient's past experience with a traumatic brain injury (TBI), indicating that the acute phase of the injury has resolved. It is used when the TBI is no longer an active problem but is relevant to the patient's current health status or future care. This history may influence treatment decisions, prognosis, or risk assessment for subsequent conditions.

Apply this code when documenting a patient's medical history that includes a resolved TBI, regardless of the severity or type of the original injury (e.g., concussion, contusion, penetrating injury). It is appropriate for follow-up appointments, routine physicals, or when the history of TBI is pertinent to the current encounter, such as assessing for post-concussive syndrome or other long-term sequelae.

• Do not use this code for active or acute traumatic brain injuries; instead, use the appropriate codes from the S06 category.
• Ensure documentation clearly states a history of TBI, not a current injury.
• Remember the "Excludes1" note: do not code this alongside Z86.73 for personal history of TIA or cerebral infarction without residual deficits.