Concussion w loss of consciousness of unsp duration, init

This code signifies a concussion, a mild traumatic brain injury, where the patient experienced a period of unconsciousness of an unknown length. It indicates the initial medical evaluation and treatment for this specific injury. The injury typically results from a direct blow to the head or an indirect force causing the brain to move rapidly within the skull.

Use this code when documentation clearly states a diagnosis of concussion accompanied by a loss of consciousness, but the duration of unconsciousness is not specified. This code is appropriate for the very first encounter a patient has with a healthcare provider for this particular injury. Supporting documentation would include physician notes detailing the mechanism of injury, symptoms consistent with concussion, and confirmation of loss of consciousness without a recorded duration.

• Ensure the documentation explicitly states "loss of consciousness" and that its duration is not specified. If duration is known, a more specific code should be used.
• This "A" seventh character indicates an initial encounter for active treatment of the injury. Subsequent care would require different seventh characters (e.g., D for subsequent, S for sequela).
• Always code any associated external cause of injury (e.g., fall, motor vehicle accident) with an appropriate external cause code.