2021 ICD-10-CM Code S06.309S

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

  1. ICD-10-CM Index
  2. Chapter: S00–T98
  3. Section: S00-S09
  4. Block: S06
  5. S06.309S - Unsp focal TBI w LOC of unsp duration, sequela
Version 2021
Billable Code
7th Character Code
Unspecified Code
Sequela Code
POA Exempt

Valid for Submission

S06.309S is a billable diagnosis code used to specify a medical diagnosis of unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, sequela. The code S06.309S is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions.

The ICD-10-CM code S06.309S 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. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

S06.309S is a sequela code, includes a 7th character and should be used for complications that arise as a direct result of a condition like unspecified focal traumatic brain injury with loss of consciousness of unspecified duration. According to ICD-10-CM Guidelines a "sequela" code should be used for chronic or residual conditions that are complications of an initial acute disease, illness or injury. The most common sequela is pain. Usually, two diagnosis codes are needed when reporting sequela. The first code describes the nature of the sequela while the second code describes the sequela or late effect.

Unspecified diagnosis codes like S06.309S 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:S06.309S
Short Description:Unsp focal TBI w LOC of unsp duration, sequela
Long Description:Unspecified focal traumatic brain injury with loss of consciousness of unspecified duration, sequela

Code Classification

Approximate Synonyms

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

Present on Admission (POA)

S06.309S is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions
POA Indicator CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert S06.309S to ICD-9 Code

The General Equivalency Mapping (GEM) crosswalk indicates an approximate mapping between the ICD-10 code S06.309S its ICD-9 equivalent. The approximate mapping means there is not an exact match between the ICD-10 code and the ICD-9 code and the mapped code is not a precise representation of the original 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)

Previous Code: S06.309D

Related Codes

Next Code: S06.31