N84.0 - Polyp of corpus uteri

Clinical Definition

A mild traumatic brain injury (MTBI), commonly known as a concussion, is a temporary disruption of brain function typically caused by a bump, blow, or jolt to the head. This trauma causes the brain to move rapidly within the skull.

Documentation Requirements

• Initial vs. Subsequent: Must specify if this is the initial encounter, subsequent encounter, or sequela

• Loss of Consciousness: Document exact duration if any:

  • None

  • Under 30 minutes

  • 30-59 minutes

  • Duration unknown

• Mechanism of Injury: Document specific cause:

  • Fall

  • Motor vehicle accident

  • Sports injury

  • Assault

• Associated Symptoms: Must note presence/absence of:

  • Headache

  • Dizziness

  • Memory issues

  • Nausea/vomiting

Common Synonyms

• Concussion

• Getting your "bell rung"

• Head injury

• Getting "knocked out"

• Sports concussion

Coding Conflicts

• Excludes1:

  • Diffuse traumatic brain injury (S06.2-)

  • Focal traumatic brain injury (S06.3-)

• Excludes2:

  • Post-concussion syndrome (F07.81)

  • Head injury NOS (S09.90)

Scribing.io Automation

The AI scribe automatically identifies key concussion-related terminology during the encounter, including:

• LOC duration phrases ("out for 2 minutes")

• Mechanism descriptors ("hit head during soccer")

• Symptom clusters ("dizzy, nauseous after impact")

• Glasgow Coma Scale components when documented

• Associated neurological findings

The system flags if any required elements are missing before encounter closure.