Health Information Management

Tip: Additional documentation needed for Glasgow coma scale in ICD-10

APCs Insider, November 19, 2010

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In ICD-10-CM, clinicians may use the Glasgow coma scale codes that follow in conjunction with traumatic brain injury codes or sequelae of cerebrovascular accident codes. These codes are primarily for use by trauma registries, but coders may report them for any setting where this information is collected.

At a minimum, facilities must report the initial score documented on presentation at the facility. This may be a score from the emergency medicine technician (EMT) or in the ED. If the patient expires in the ED before being admitted to an inpatient unit, coders will report the case as an outpatient encounter.
One code from each of the three subcategories (R40.21-, R40.22-, and R40.23-) is needed to complete the scale. Therefore, the clinician must document the patient’s visual, verbal, and motor status in the medical record.

When coding a patient’s visual status, look for documentation of how often the patient’s eyes are open and select the appropriate code:

  • R40.211 (coma scale, eyes open, never)
  • R40.212 (coma scale, eyes open, to pain)
  • R40.213 (coma scale, eyes open, to sound)
  • R40.214 (coma scale, eyes open, spontaneous)

Then, do the same for the patient’s verbal and motor skills. Physicians will need to document the patient’s best verbal and best motor response for coders to select the most appropriate code.

The clinician must also document the time in which the coma scale is recorded in order to assign the appropriate seventh character as 0 (unspecified time), 1 (in the field [EMT or ambulance]), 2 (at arrival to emergency department), 3 (at hospital admission), or 4 (24 hours or more after hospital admission).

This tip was adapted from "Learn what areas require more physician documentation" in the November issue of Briefings on APCs.

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