Coding Tip: Importance of Reporting Glasgow Coma Scale
RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
Prior to October 1, 2016, the coma scale was only reported in conjunction with traumatic brain injuries, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. Coders should now be reporting the GCS when documented on any case where there is monitoring of the central nervous system regardless of the medical condition requiring the monitoring.
The documentation of the coma scale may be found documented by other clinicians involved in the care of the patient (EMT, nursing) and not only by the physician. The physician must have documented the associated diagnosis (why the GCS is being addressed) such as encephalopathy, stroke, overdose, etc.
When reporting the GCS, a code from each category is needed to complete the scale. At a minimum, report the initial score documented on presentation to your facility. This may be from EMT or from the ED. Only report the total score when there is no documentation in the record indicating the individual scores.
The 7th character indicates when the scale was recorded and should match for all three codes when reporting the individual scores.
Did you know that some of the GCS are MCC’s when grouped with certain diagnoses? R40.2214 (coma scale, best verbal response, none, 24 hours or more after hospital admission) is an MCC for a patient with an overdose, pneumonia, encephalopathy, and intestinal disorders along with many/most other selections of PDX. These codes can also impact the SOI/ROM when reported.
Please check with the facility that you are coding for to determine how they want these captured. Some facilities are capturing them only on arrival and others are capturing multiple times while some are only capturing the total number. It is important that these are reported appropriately since they do impact the DRG and SOI/ROM on some cases.
Here’s a couple of examples of when reporting the GCS would impact the DRG and/or SOI/ROM:
- Patient is found in their nursing home with labored breathing and ambulance is called. The patient is found to have a possible pneumonia and transported to the ED. The patient is confused and unable to respond to any questions and is nonverbal in the ambulance and does not open their eyes. Motor response is documented as abnormal by EMT. On discharge the patient is diagnosed with pneumonia (J18.9) and sent back to the nursing home. The coder should also assign R40.2211 (Coma scale, best verbal response, none, in the field [EMT or ambulance]), R40.2111 (Coma scale, eyes open, never, in the field [EMT or ambulance]), and R40.2331 (Coma scale, best motor response, abnormal, in the field [EMT or ambulance]). These codes result in MS-DRG 193 (Simple Pneumonia and Pleurisy with MCC.) The APR-DRG is 139 (Other pneumonia) with an SOI as 3-Major and ROM as 4-Extreme. If the GCS codes are taken away and only the total is reported (which was 3-R40.2431) the result is MS-DRG 195 (Simple Pneumonia and Pleurisy without CC/MCC) and APR DRG 139, Other Pneumonia with an SOI as 1-Minor and ROM as 1-Minor.
- Patient is brought into the ED with possible OD of heroin. The patient is found on presentation to the ED to be nonverbal, does not open eyes and has no motor responses. The patient is admitted to ICU and monitored and responds to treatment. The OD is determined to be accidental as the patient denies any suicidal intent or thoughts. Patient is discharged with accidental heroin OD. The coder should assign T40.1X1A (Poisoning by heroin, accidental (unintentional), initial encounter) as well as R40.2312 (Coma scale, best motor response, none, at arrival to emergency department), R40.2112 (Coma scale, eyes open, never at arrival to emergency department) and R40.2212 (Coma scale, best verbal response, none, at arrival to emergency department). These codes result in MS-DRG 917 (Poisoning and Toxic Effects of Drugs with MCC). The APR-DRG is 816 (Toxic effects of non-medicinal substances) with an SOI as 3-Major and ROM as 4-Extreme. If the individual GCS codes are taken away and only the total score reported R40.2212 the result is MS-DRG 918 (Poisoning and Toxic Effects of Drugs without MCC). APR-DRG is 816, Toxic effects of non-medicinal substances and an SOI as 1-Minor and ROM as 1-Minor.
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.