Diffuse TBI w/o loss of consciousness, subs

This code signifies a brain injury resulting from widespread trauma, such as from acceleration-deceleration forces, where the patient did not experience any loss of consciousness at the time of injury. It indicates that the patient is receiving follow-up care for this specific type of brain injury.

Apply this code for patients presenting for ongoing evaluation, treatment, or rehabilitation of a diffuse traumatic brain injury where the initial injury did not involve a loss of consciousness. Documentation should clearly state "diffuse TBI," "no loss of consciousness," and indicate a "subsequent encounter" or follow-up visit for the injury.

• Ensure documentation explicitly states "without loss of consciousness" to differentiate from codes indicating LOC.
• Verify that the encounter is indeed subsequent; initial treatment would require an "A" seventh character.
• Do not confuse with focal brain injuries; this code is specifically for diffuse trauma.