Coding Tip: Importance of Reporting Glasgow Coma Scale

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.

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Coding Tip: Reporting Pressure Ulcers

A change has been made in how coders will report pressure ulcers when the stage of the ulcer changes during the admission. Per the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 51, if a patient presents with a pressure ulcer at one stage and during the admission it progresses to a higher stage, two separate codes would be reported. One for the site and stage of the ulcer on admission and another for the same ulcer and the highest stage reported during the admission.

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