Coding Tip: Coding the Glasgow Coma Scale (GCS)

by | Feb 26, 2016 | Coding Tips, Education, ICD-10 | 0 comments

Kim Carrier
RHIT, CDIP, CCS, CCS-P

Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

With the implementation of ICD-10-CM, the GCS should be reported (when documented) on traumatic brain injuries, acute cerebrovascular disease, and sequelae of cerebrovascular records.

The GCS is a scale that assesses the degree of consciousness of patients with traumatic brain injury or cerebrovascular disease.  Three factors are used in the scoring: amount of eye opening, verbal response, and motor response.

  • Coders may take this information from physician documentation and documentation by other personnel directly related to the care of the patient as long as there is no conflicting documentation (emergency medical technician, consultants, ED, residents, anesthesiologist, etc.)
  • Coders may use the documented numeric values when documented rather than the descriptions
  • Only report the total score when the individual scores are not documented
  • GCS codes would be reported as secondary diagnoses only
  • GCS codes may be reported multiple times (depending on your facility guidelines) but at a minimum the initial score upon presentation should be reported
  • The seventh character for the codes should match for all three codes reported for individual scores

References: I-10 Coding Handbook; Coding Clinic, First Quarter ICD-10 2014 Pages: 19-20; Coding Clinic, Second Quarter ICD-10 2015 Pages: 17-18

 

Happy Coding!

The information contained in this coding advice 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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