Diffuse TBI w LOC >24 hr w return to consc levels, sequela

This code signifies a widespread brain injury resulting from trauma, where the patient experienced a coma lasting over 24 hours but subsequently recovered to their baseline level of consciousness. It specifically indicates a long-term consequence or late effect of this severe traumatic brain injury.

Apply this code when documenting the sequelae of a diffuse traumatic brain injury that initially caused a prolonged loss of consciousness (greater than 24 hours) and the patient has since returned to their pre-injury conscious state. Documentation should clearly state the history of the TBI, the duration of unconsciousness, and the current neurological status indicating a return to baseline.

• Requires a seventh character 'S' for sequela, indicating a late effect of the injury.
• Do not use for acute TBI encounters; this code is for follow-up care related to the lasting effects.
• Ensure documentation specifies "diffuse" injury and the exact duration of unconsciousness to differentiate from other TBI codes.