Unsp focal TBI w/o loss of consciousness, subs

This code signifies a focal traumatic brain injury (TBI) where the specific type of focal injury (e.g., contusion, laceration) is not documented, and the patient did not experience loss of consciousness at the time of injury. The "D" seventh character indicates that this is a subsequent encounter for care after the initial treatment phase, such as follow-up visits or ongoing management of complications.

Use this code for follow-up appointments, rehabilitation, or ongoing management of an unspecified focal TBI without loss of consciousness. Documentation should clearly state the patient is beyond the initial acute phase of treatment and is receiving care related to the sequelae or recovery from the injury. The medical record must explicitly state "unspecified focal TBI" or lack specificity regarding the focal injury type.

• Ensure the documentation confirms no loss of consciousness at the time of injury.
• Verify the encounter is for subsequent care; otherwise, an "A" (initial encounter) or "S" (sequela) seventh character would be more appropriate.
• Avoid using this code if a more specific focal TBI diagnosis (e.g., cerebral contusion) is documented.