Diffuse TBI with LOC status unknown, sequela

This code signifies a widespread traumatic brain injury where the patient's level of consciousness immediately following the injury is not documented. It specifically indicates that the injury is a sequela, meaning it represents a residual condition or late effect of a previous TBI.

Apply this code when documentation confirms a diffuse traumatic brain injury and the patient is presenting for treatment of a long-term complication or residual effect of that injury. This code is appropriate when the initial loss of consciousness status was not recorded or is unknown. Documentation should clearly state "sequela" or describe a chronic condition resulting from a past TBI.

• Always sequence this code after the acute TBI code if the patient is still in the acute phase of treatment.
• Ensure documentation explicitly states "sequela" or describes a chronic condition directly attributable to a past TBI.
• Do not use this code for acute TBI; it is specifically for the long-term effects.