Coma CDI Scenario – May 2021

Topic: Coma

H&P: 65-year-old female presenting with obtundation. Per report patient was in her usual state of health until the AM of date of admission when she suffered a sudden onset and progressive worsening headache. Family notes she progressed from lethargy to obtundation at which time EMS was called. Patient noted to have pressures in the 200s which were treated with nicardipine on arrival.

PMH: DM2, HTN, tobacco abuse

Home Medications: Actos 30mg QD,Metoprolol 50mg QD

Vitals: 98.6, HR 90, BP 210/90 RR 16 SPo2 82% on NRB

PE: GCS E1V1M2. Eyes do not open to voice/touch/pain. Follows/mimics no commands.

Labs: WBC 12.2, HB 11.5, Glucose 304, Creatinine 1.61, GFR 45

CT Head: Pontine hemorrhage with extension into the ventricles. Moderate amount of vasogenic edema present.

Admitting Diagnosis: Hypertensive Pontine hemorrhage with extension into the ventricles in the setting of cardiovascular risk factors, AMS, Acute Kidney Failure, HTN Emergency and unable to protect airway. Plan: Intubate

Neuro Consult: Large pontine hemorrhage with exam evidence of severe neurologic and brainstem dysfunction. Edema present on CT-start 3% Saline gtt

Discharge Summary: Palliative care was consulted for assistance for goals of care and family ultimately decided to transition to hospice. Code status changed to DNR. Discharge Diagnoses: Pontine hemorrhage with extension into ventricles, altered mental status, acute kidney failure, and hypertensive emergency.

Question: Are there query opportunities based on the scenario stated above?

Discussion:

  • Provider documents a total Glasgow Coma Scale (GCS) score of 4 on arrival and patient was subsequently intubated as she was unable to protect their airway
  • 3% Saline gtt started for ‘edema’ seen on CT
  • Pt. demonstrated obtundation with a Sp02 of 82% on NRB with plan to intubate

UASI Recommends:

  • Query for Coma
  • Query for Cerebral Edema
  • Query for Acute Hypoxic Respiratory Failure

Documentation without Clarification:

  • Principal Diagnosis: Nontraumatic intracerebral hemorrhage in brain stem(I61.3)
  • Secondary Diagnoses: Hypertensive emergency (I16.1); Acute kidney failure, unspecified (N17.9); Nontraumatic intracerebral hemorrhage, intraventricular (I61.5); Type 2 diabetes mellitus without complication (E11.9), Do not resuscitate (Z66); Essential (primary) hypertension (I10).
  • Working DRG: 065 Intracranial hemorrhage or cerebral infarction w CC or tPA in 24 hr
  • RW: 1.0182         GLMOS: 2.9        SOI/ROM: 2/2

Documentation with Clarification:

  • Principal Diagnosis: Nontraumatic intracerebral hemorrhage in brain stem(I61.3)
  • Secondary Diagnoses: Hypertensive emergency (I16.1); Acute kidney failure, unspecified (N17.9); Nontraumatic intracerebral hemorrhage, intraventricular (I61.5); Type 2 diabetes mellitus without complication (E11.9), Do not resuscitate (Z66); Essential (primary) hypertension (I10); Acute respiratory failure with hypoxia (J9601); Cerebral edema (G93.6); Unspecified coma (R40.20)
  • Working DRG 064 Intracranial hemorrhage or cerebral infarction with MCC
  • RW: 1.913           GLMOS: 4.4        SOI/ROM: 4/4

CDI Educational Tips:

Coma (R40.20) is a symptom code. Documentation and querying, should indicate the etiology of the coma.

The Glasgow Coma Scale is based on the patient’s best response in three areas:

  • Eye opening (score 1-4)
  • Verbal Response (score 1-5)
  • Motor Response (score 1-6)

The lowest possible total GCS is 3 (deep coma), while the highest is 15 (fully awake person)

  • 3-8 points = Severe: Coma
  • 9-12 points = Moderate: Stupor/obtundation
  • 13-15 points = Minor: Lethargy

Query for Coma when the total GSC is ≤8. Physicians often use a variation of descriptive terms to describe a patient in a coma, such as unresponsive, obtunded, or stupor. Review the record closely to identify terms that accurately describe the patient’s presentation and portray the severity of illness and risk of mortality, and query when evidence is present for more specific diagnostic terms.

Inclusion terms listed below R40.20 include coma NOS and unconsciousness NOS. Please note temporary unconsciousness would not indicate clinical significance for Coma. If the significance is unclear, a query should be left to clarify.

FY21 Official Coding Guidelines have been revised regarding GSC and read: The coma code (R40.2-) can be used in conjunction with traumatic brain injury codes. These codes are primarily for use by trauma registries, but they may be used in any setting where the information is collected. The coma scale codes should be sequenced after the diagnosis code(s).

Therefore, for the new revision, GSC codes only pertain to trauma cases. While the Glasgow Coma Scale can no longer be reported on non-trauma related cases, coma can be and is, an MCC.  A query should be considered when the patient’s Glasgow Coma Scale score is less than or equal to 8.

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.

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