Concussion with moderate loss of consciousness

This code signifies a concussion where the patient experienced a moderate period of unconsciousness following head trauma. A concussion is a mild traumatic brain injury resulting in a temporary disturbance of brain function, and "moderate" loss of consciousness typically implies a duration greater than 30 minutes but less than 6 hours.

Apply this code when medical record documentation clearly states a diagnosis of concussion and specifies a moderate loss of consciousness. This would be supported by physician notes detailing the duration of unconsciousness after a head injury, such as from a fall, assault, or motor vehicle accident.

• Differentiate from mild (less than 30 minutes) or severe (greater than 6 hours) loss of consciousness, which are coded separately.
• Ensure the documentation explicitly states "concussion" and the duration or classification of loss of consciousness.
• Always code the external cause of injury (E-code) in addition to the concussion code to provide a complete picture of the event.