Unsp focal TBI w LOC >24 hr w ret consc lev, subs

This code signifies a follow-up encounter for an unspecified focal traumatic brain injury (TBI) where the patient experienced a loss of consciousness exceeding 24 hours but has since returned to their baseline neurological status. It indicates ongoing management or assessment after the acute phase of a severe TBI.

Use this code for subsequent visits when a patient is recovering from a focal TBI with prolonged loss of consciousness, and their consciousness level has normalized. Documentation should confirm the focal nature of the injury, the duration of unconsciousness, and the patient's current return to pre-injury conscious state.

• Ensure documentation clearly specifies "focal" TBI; otherwise, an unspecified TBI code may be more appropriate.
• Verify the duration of loss of consciousness (LOC) is explicitly stated as "greater than 24 hours" and that the patient has returned to baseline consciousness.
• This "D" encounter code is used after the initial treatment of the injury; for initial treatment, an "A" encounter code would be used.