Concussion with no loss of consciousness

This code signifies a mild traumatic brain injury resulting from a direct or indirect impact to the head, characterized by transient neurological dysfunction without any period of unconsciousness. Patients may experience symptoms such as headache, dizziness, confusion, or memory disturbance immediately following the injury.

Apply this code when documentation clearly indicates a concussion diagnosis and explicitly states that there was no loss of consciousness. This is appropriate for patients presenting with concussion symptoms following head trauma, where the medical record confirms the absence of any altered mental status beyond transient confusion.

• Ensure the physician's documentation explicitly states "no loss of consciousness" or similar phrasing.
• Do not use this code if any period of unconsciousness, however brief, is documented; refer to codes for concussion with loss of consciousness.
• Sequence this code as the primary diagnosis when it is the reason for the encounter.