What two things must be present to code loss of consciousness (LOC)?

The correct answer involves the presence of evidence of head trauma and a formal diagnosis by a physician, as both elements are critical for coding loss of consciousness (LOC). Evidence of head trauma can suggest the potential cause of LOC, making it pertinent for proper coding. A diagnosis by a physician validates the occurrence of LOC and confirms that it has been assessed and diagnosed appropriately in a clinical context.

In cases of LOC, it is essential to rely on medical evaluations to establish the condition definitively. While other factors may contribute to the understanding of a patient’s condition or symptomatology, they do not hold the same weight in the context of coding for loss of consciousness. For instance, immediate medical intervention and imaging results are important for treatment but do not necessarily influence the coding criteria directly. Similarly, a patient’s self-report and physical examination provide valuable insights into the patient's state but do not substitute for the necessary clinical diagnosis. Witness testimony and cognitive assessments may be informative, particularly in understanding the event’s context, but again, they do not fulfill the coding requirements without the essential supporting elements of head trauma evidence and physician diagnosis.