Unsp focal TBI w LOC of 30 minutes or less, init

This code signifies a traumatic brain injury that is localized to a specific area of the brain, rather than diffuse, and the exact nature of the focal injury is not specified. The patient experienced a brief period of unconsciousness, lasting 30 minutes or less, as a direct result of the trauma. This code is used for the initial phase of treatment for this injury.

Apply this code when documentation indicates a patient sustained a focal traumatic brain injury with a documented loss of consciousness (LOC) of 30 minutes or less, and the specific type of focal injury (e.g., contusion, laceration) is not yet determined or specified. This is appropriate for the first encounter for treatment of the injury.

• Ensure documentation clearly states "focal" TBI and specifies LOC duration as 30 minutes or less.
• Do not use if the specific focal injury (e.g., contusion, hemorrhage) is identified; instead, code to the more specific diagnosis.
• The "A" seventh character indicates an initial encounter for active treatment of the injury.