2021 ICD-10-CM Code S06.309

Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration

Version 2021

Not Valid for Submission

S06.309 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of unspecified focal traumatic brain injury with loss of consciousness of unspecified duration. The code is not specific and is NOT valid for the year 2021 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.

The ICD-10-CM code S06.309 might also be used to specify conditions or terms like closed fracture of base of skull, closed fracture of base of skull with intracranial hemorrhage, closed fracture of vault of skull, closed fracture of vault of skull with intracranial hemorrhage, closed skull fracture with intracranial hemorrhage , closed skull fracture with intracranial hemorrhage, etc.

Unspecified diagnosis codes like S06.309 are acceptable when clinical information is unknown or not available about a particular condition. Although a more specific code is preferable, unspecified codes should be used when such codes most accurately reflect what is known about a patient's condition. Specific diagnosis codes should not be used if not supported by the patient's medical record.

ICD-10:S06.309
Short Description:Unsp focal TBI w loss of consciousness of unsp duration
Long Description:Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration

Code Classification

Coding Guidelines

The appropriate 7th character is to be added to each code from block Intracranial injury (S06). Use the following options for the aplicable episode of care:

Specific Coding for Unsp focal TBI w loss of consciousness of unsp duration

Non-specific codes like S06.309 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for unsp focal tbi w loss of consciousness of unsp duration:

  • BILLABLE CODE - Use S06.309A for initial encounter
  • BILLABLE CODE - Use S06.309D for subsequent encounter
  • BILLABLE CODE - Use S06.309S for sequela

Tabular List of Diseases and Injuries

The Tabular List of Diseases and Injuries is a list of ICD-10 codes, organized "head to toe" into chapters and sections with coding notes and guidance for inclusions, exclusions, descriptions and more. The following references are applicable to the code S06.309:


Inclusion Terms

Inclusion Terms
These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

Information for Patients


Traumatic Brain Injury

Also called: Acquired brain injury, TBI

Traumatic brain injury (TBI) happens when a bump, blow, jolt, or other head injury causes damage to the brain. Every year, millions of people in the U.S. suffer brain injuries. More than half are bad enough that people must go to the hospital. The worst injuries can lead to permanent brain damage or death. Half of all TBIs are from motor vehicle accidents. Military personnel in combat zones are also at risk.

Symptoms of a TBI may not appear until days or weeks following the injury. A concussion is the mildest type. It can cause a headache or neck pain, nausea, ringing in the ears, dizziness, and tiredness. People with a moderate or severe TBI may have those, plus other symptoms:

Health care professionals use a neurological exam and imaging tests to assess TBI. Serious traumatic brain injuries need emergency treatment. Treatment and outcome depend on how severe the injury is. TBI can cause a wide range of changes affecting thinking, sensation, language, or emotions. TBI can be associated with post-traumatic stress disorder. People with severe injuries usually need rehabilitation.

NIH: National Institute of Neurological Disorders and Stroke


[Learn More in MedlinePlus]

Code History

  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016 (First year ICD-10-CM implemented into the HIPAA code set)