Diffuse TBI w loss of consciousness of 1-5 hrs 59 min, subs

This code signifies a widespread traumatic brain injury where the patient experienced a loss of consciousness lasting between one hour and five hours and fifty-nine minutes. It specifically applies to a subsequent encounter, meaning the patient is receiving follow-up care for this previously diagnosed injury.

Apply this code when a patient presents for ongoing management, rehabilitation, or evaluation of a diffuse TBI with a documented loss of consciousness within the specified timeframe. Documentation should clearly indicate the diffuse nature of the injury, the duration of unconsciousness, and that this is not the initial presentation for the injury.

• Ensure documentation explicitly states "diffuse" TBI and the exact duration of loss of consciousness for accurate subcategory selection.
• Verify that the encounter is indeed "subsequent" and not an initial presentation; otherwise, an acute phase code would be more appropriate.
• Do not confuse with focal TBI codes or codes for TBI without loss of consciousness, as these require different specificity.