Glasgow Coma Scale Coding OCG Update

The FY2021 Official Guidelines for Coding and Reporting made a change that was not clearly evident in the past guidelines. Below you will see that the lines for using the coma scale codes for “acute cerebrovascular disease or sequelae of cerebrovascular disease codes” and “The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition,” have been removed for the Glasgow coma scale code guidelines regarding coma scale code assignment. This indicates that the Glasgow coma scale codes should be used in conjunction with traumatic brain injury codes only beginning with discharges October 1, 2020. AHA discussed this change in the 4Q2020 Coding Clinic.

 

HIA also sent a letter to AHA and they confirmed that the guideline has been changed back to the original directive that the GCS codes ONLY be used for cases involving traumatic brain injury.  The Cooperating Parties decided to roll back the GCS codes to their original intent to avoid confusion in application.

In 2024 another update was made.  The following was added and reflects the most recent guidelines:

Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

e. Coma Code R40.20, Unspecified coma, should may be assigned when the underlying cause of the coma is not known, or the cause is a traumatic brain injury and the coma scale is not documented in the medical record.

Do not report codes for unspecified coma, individual or total Glasgow coma scale scores for a patient with a medically induced coma or a sedated patient.

1) Coma Scale

The coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes. These codes cannot be used with code R40.2A, Nontraumatic coma due to underlying condition. They are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).

These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.

PREVIOUS FY2020 ICD-10-CM Official Guidelines for Coding and Reporting FY 2020
e. Coma scale
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition. The coma scale codes should be sequenced after the diagnosis code(s).

These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.

References
Official Guidelines for Coding and Reporting
AHA Letter Reference #50039169.1020


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The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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