Concussion Management 101

What is a concussion?

As a healthcare professional, you’re likely familiar with patients who come in after a head injury, but diagnosing a concussion can sometimes be tricky, especially when symptoms aren’t immediately obvious.

A concussion is a type of brain injury that occurs due to a blow to the head or a significant force impacting the body. This can happen even if the person remains conscious, which is more common than most people realize. In fact, only about 10% of concussions involve someone being knocked out (NHS Inform, 2025).

Medically, a concussion is defined as a temporary loss of normal brain function caused by mechanical trauma, leading to a temporary alteration in brain function (Agarwal et al., 2024). The most common causes are falls and physical violence, but sport-related concussions are also prevalent, particularly in contact sports like football or rugby.

People with a history of repeated concussions or mild traumatic brain injury (TBI) often face longer recovery times. They may develop lasting issues with memory, concentration, or balance (U.S. Centers for Disease Control and Prevention, 2024). If you suspect a patient has a concussion, it’s crucial to stop them from continuing any physical activity immediately. While some individuals may appear fine right after the injury, symptoms can develop over time, making monitoring and follow-up essential.

Concussion symptoms

Concussion symptoms can appear immediately but may take several hours to show. If someone has suffered a concussion, look for changes in their behavior or physical condition, such as:

• Confusion or a blank expression
• Slow to respond to questions
• Difficulty balancing or dizziness
• Unusual emotional reactions (e.g., laughing or crying without cause)
• Irritability or behavior out of character
• Memory issues (before or after the injury)
• Headache
• Dizziness or balance problems
• Nausea or vomiting
• Vision disturbances (blurry or “seeing stars”)

Symptoms like ringing ears, sensitivity to light, or trouble sleeping may also occur in some cases. If any of these signs are present after a head injury, it’s essential to consult with a healthcare professional as soon as possible to ensure proper care and management.

Causes

Concussions can result from more than just a direct blow to the head. Other common causes of concussion include:

• Falls (especially in children and older adults)
• Motor vehicle accidents
• Physical assaults or domestic violence
• Impact during contact sports (e.g., rugby, football, hockey)
• Being hit by an object (e.g., ball, bat, or equipment)
• Military-related blast injuries

In sport-related concussion cases, it’s especially important to stop physical activity immediately after the impact since it can make symptoms worse. Regardless of the cause, prompt assessment helps prevent further complications and supports a safer recovery.

Potential complications

While most concussions resolve with proper rest and care, some patients experience longer-term effects that may interfere with daily functioning. These complications can appear days or even weeks after the initial injury, especially if the concussion goes unrecognized or is not managed appropriately.

Possible complications include:

• Post-concussion syndrome (symptoms like headache, dizziness, and trouble concentrating, lasting weeks or months)
• Ongoing memory or concentration issues
• Increased sensitivity to light and noise
• Mood changes, such as anxiety, depression, or irritability
• Sleep disturbances or chronic fatigue
• Second impact syndrome (a rare but serious condition if a second concussion occurs before full recovery)

In children, concussions may lead to some developmental problems. Early recognition and follow-up can significantly reduce the chance of long-term complications.

How to diagnose concussion

Diagnosing a concussion is primarily a clinical assessment based on the mechanism of injury, reported symptoms, and observed signs. No single test confirms a concussion, so it requires careful evaluation by a healthcare professional. Here are some methods usually used to diagnose concussion:

Patient history and description of injury

Start by gathering a detailed account of how the injury occurred. Ask about the force of impact, whether there was a loss of consciousness, and what symptoms the patient has experienced since the incident. Also, check for any memory gaps before or after the injury.

Symptom assessment

Use a symptom checklist to guide the evaluation. This may include asking about headaches, dizziness, nausea, visual changes, sensitivity to light or noise, difficulty concentrating, or sleep disturbances.

Neurological examination

Perform a focused neurological exam to assess mental status, coordination, balance, and cranial nerve function. Look for signs like delayed responses, trouble balancing, or unusual eye movements.

Cognitive testing

Simple cognitive tests can help assess memory, attention, and orientation. You might ask the patient to recall words, repeat numbers backward, or describe the date and time.

Imaging tests

CT or MRI scans are not routinely used for diagnosing concussion because they do not show any abnormalities. Still, they may be ordered if there are red flags suggesting a more serious injury, such as prolonged unconsciousness, worsening headache, repeated vomiting, or seizures.

How are concussions managed?

Effective concussion management supports full recovery and prevents further injury. Below are the key steps in managing concussions:

Rest and symptom monitoring

In the first 24–48 hours after a concussion, patients should avoid physical and mental exertion to give the brain time to heal. Monitoring for worsening symptoms, such as severe headache or repeated vomiting, is critical during this period. Patients and families should know what to watch for and when to seek further medical attention.

Gradual return to activity

Light physical activity can be gradually reintroduced after the initial rest phase as symptoms improve. A stepwise approach is used, where the patient progresses through stages of increasing activity, starting with light walking and eventually returning to full daily tasks or sports. Each stage of this process should only begin if the patient is symptom-free from the previous stage.

For athletes, physicians can follow structured, evidence-based guidelines for selected issues in sport-related concussion, such as those provided by the Team Physician Consensus Conference (Herring et al., 2021), to help ensure safe and effective concussion management throughout recovery.

Cognitive support and accommodations

Some patients may need temporary academic or work adjustments during concussion recovery. This might include shorter school days, extra breaks, or reduced screen time. Supporting brain function while avoiding overstimulation is essential in treating brain injuries.

Moreover, educating patients and families about the expected course of recovery can help reduce anxiety and improve adherence to the management plan. If they follow medical advice, most people recover fully from a concussion within a few weeks.

Concussion ICD codes

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) system is used to classify and code diseases, injuries, and other health conditions. It helps in accurately diagnosing, documenting, and billing for medical conditions and treatments.

The S06.0 category of ICD codes specifically relates to concussions. Here are the relevant billable codes:

• S06.0X0A: Concussion without loss of consciousness, initial encounter
• S06.0X0D: Concussion without loss of consciousness, subsequent encounter
• S06.0X0S: Concussion without loss of consciousness, sequela
• S06.0X1A: Concussion with loss of consciousness of 30 minutes or less, initial encounter
• S06.0X1D: Concussion with loss of consciousness of 30 minutes or less, subsequent encounter
• S06.0X1S: Concussion with loss of consciousness of 30 minutes or less, sequela
• S06.0XAA: Concussion with loss of consciousness status unknown, initial encounter
• S06.0XAD: Concussion with loss of consciousness status unknown, subsequent encounter
• S06.0XAS: Concussion with loss of consciousness status unknown, sequela
• S06.0X9A: Concussion with loss of consciousness of unspecified duration, initial encounter
• S06.0X9D: Concussion with loss of consciousness of unspecified duration, subsequent encounter
• S06.0X9S: Concussion with loss of consciousness of unspecified duration, sequela

These codes are used to accurately document and categorize different types of concussions based on the patient's symptoms and medical encounter.

Carepatron concussion-related tools you can use

Carepatron offers many resources to support you beyond practice management, ensuring you have the tools for effective patient care. Here are some concussion-related tools you can use:

• Post-Concussion Syndrome Treatment Guidelines
• Sport Concussion Assessment Tool, 5th Edition (SCAT5)
• Concussion Symptom Checklist

These resources aim to help you better assess and manage concussion-related cases. You can also access treatment plans, intake forms, and other helpful templates to make your work easier and more efficient.

References

Agarwal, N., Thakkar, R., & Than, K. (2024, April 29). Concussion. American Association of Neurological Surgeons. https://www.aans.org/patients/conditions-treatments/concussion/

Herring, S., Kibler, W. B., Putukian, M., Solomon, G. S., Boyajian-O’Neill, L., Dec, K. L., Franks, R. R., Indelicato, P. A., LaBella, C. R., Leddy, J. J., Matuszak, J., McDonough, E. B., O’Connor, F., & Sutton, K. M. (2021). Selected issues in sport-related concussion (SRC | mild traumatic brain injury) for the team physician: a consensus statement. British Journal of Sports Medicine, 55(22). https://doi.org/10.1136/bjsports-2021-104235

NHS Inform. (2025, February 21). Concussion symptoms and treatment. https://www.nhsinform.scot/illnesses-and-conditions/injuries/head-and-neck-injuries/concussion/

U.S. Centers for Disease Control and Prevention. (2024, May 16). About mild TBI and concussion. Traumatic Brain Injury & Concussion. https://www.cdc.gov/traumatic-brain-injury/about/index.html