Unsp focal TBI w loss of consciousness of 31-59 min, subs

This code signifies a traumatic brain injury (TBI) where the specific type of focal injury (e.g., contusion, laceration) is not documented, and the patient experienced a loss of consciousness lasting between 31 and 59 minutes. The "D" indicates this is a subsequent encounter, meaning the patient is receiving routine care during the healing or recovery phase of the injury.

Apply this code when documentation confirms an unspecified focal TBI with a documented loss of consciousness between 31 and 59 minutes, and the patient is being seen for follow-up care, rehabilitation, or management of sequelae after the initial acute treatment. This code is appropriate when the specific nature of the focal injury (e.g., contusion, hemorrhage) is not specified by the provider.

• Ensure the medical record clearly states "unspecified focal TBI" or lacks specificity regarding the focal injury type.
• Verify the duration of loss of consciousness falls precisely within the 31-59 minute range; durations outside this range require different codes.
• Confirm the encounter is for subsequent care, not the initial acute treatment, which would use an "A" or "B" seventh character.