Concussion with prolonged loss of consciousness, without return to pre-existing conscious level

This code signifies a brain injury resulting from trauma, characterized by a sustained period of unconsciousness that extends beyond the initial impact, and where the patient has not yet regained their baseline level of awareness and responsiveness. It indicates a more severe form of concussion due to the prolonged alteration of consciousness.

Apply this code when documentation clearly indicates a concussion followed by a prolonged period of unconsciousness, and the patient's neurological status has not returned to their pre-injury conscious state. This typically involves a Glasgow Coma Scale (GCS) score indicating impaired consciousness for an extended duration post-trauma.

• Ensure documentation specifies "prolonged" loss of consciousness and explicitly states the patient has not returned to their pre-existing conscious level.
• Differentiate from concussions with brief or no loss of consciousness, or those where the patient has fully recovered to baseline.
• Always code the underlying cause of the concussion (e.g., fall, motor vehicle accident) as an external cause code (E-code) in addition to this diagnosis.