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CONDITION/DISORDER SYNONYMS

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  • Mild traumatic brain injury (mTBI)

  • Post-concussion syndrome (PCS)

  • Second impact syndrome

  • Sport-related concussion

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ICD-9-CM CODES

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  • 850 Concussion

  • 850.0 With no loss of consciousness

  • 850.11 With brief loss of consciousness (less than 30 minutes)

  • 850.12 With brief loss of consciousness (31 to 59 minutes)

  • 850.2 With moderate loss of consciousness (1 to 24 hours)

  • 850.3 With prolonged loss of consciousness and return to pre-existing consciousness level (24 hours + with full recovery)

  • 850.4 With prolonged loss of consciousness, without return to pre-existing consciousness level

  • 850.5 Loss of consciousness of unspecified duration

  • 850.9 Concussion unspecified

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ICD-10-CM CODES

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  • S06.0 Concussion

  • S06.0X0A Without loss of consciousness, initial encounter

  • S06.0X0D Without loss of consciousness, subsequent encounter

  • S06.0X0S Without loss of consciousness, sequela

  • S06.0X1 Concussion with loss of consciousness of 30 minutes or less

  • S06.0X2 Concussion with loss of consciousness of 31 minutes to 59 minutes

  • S06.0X3 Concussion with loss of consciousness of 1 hour to 5 hours 59 minutes

  • S06.0X4 Concussion with loss of consciousness of 6 hours to 24 hours, initial encounter

  • S06.0X5 Concussion with loss of consciousness greater than 24 hours with return to pre existing conscious level

  • S06.0X6 Concussion with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving

  • S06.0X7 Concussion with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness

  • S06.0X8 Concussion with loss of consciousness of any duration with death due to other cause prior to regaining consciousness

  • S06.0X9 Concussion with loss of consciousness of unspecified duration

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PREFERRED PRACTICE PATTERNS

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  • 5C: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System—congenital origin or acquired in infancy or childhood1

  • 5D: Impaired Motor Function and Sensory Integrity Associated with Nonprogressive Disorders of the Central Nervous System—acquired in adolescence or adulthood2

  • 5I: Impaired Arousal, Range of Motion, and Motor Control Associated with Coma, Near Coma, or Vegetative State3

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FIGURE 85-1

Traumatic cerebral contusion. Noncontrast CT scan demonstrating a hyperdense hemorrhagic region in the anterior temporal lobe. (From Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2012.)

Graphic Jump Location
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PATIENT PRESENTATION

A 15-year-old, male, high-school football player presents with headache, photosensitivity, balance problems, and dizziness that began approximate 5 days ago. He also reported experiencing persistent fatigue, “fogginess,” and mental sluggishness that has been present during the same period. He has a personal and family history of migraine headaches, but believes that he suffered an injury 6 days ago when he tried to tackle the starting running back for the varsity football team during the first day of summer practice.

The patient described the collision with the running back ...

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