The Glasgow Coma Scale (GCS) is a clinical scale used to measure a person’s level of consciousness after a brain injury. The scoring is determined by three factors: amount of eye opening, verbal responsiveness, and motor responsiveness.
The Glasgow Coma Scale has an adult version and a pediatric version. The pediatric version is also composed of the three tests – eye, verbal , and motor response but the individual verbal and motor responses differ from the adult scale. The Pediatric GCS is used to accommodate children up to five years of age.
The GCS codes are to be used in combination with traumatic brain injury codes. The Glasgow Coma Scale codes should be sequenced after the diagnosis codes. One code from each category is assigned to complete the scale. The seventh character indicates when the scale was recorded, i.e. in the field, at arrival to emergency department, at hospital admission, 24 hours or more after admission, or unspecified time.
In Second Quarter Coding Clinic 2021, the question was asked if it would be appropriate to report the most severe GCS score if patient’s score worsened after admission, but within the first 24 hours. Per Coding Clinic, only assign one code that represents the GCS score at the time admission with a POA of “Y” as ICD-10-CM does not classify scores that are reported after admission, but less than 24 hours later.
“Code assignment for the coma scale may be based on the medical record documentation from clinicians who are not the patient’s provider (i.e., the physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis ), because the information is typically documented by other clinicians involved in the care of the patient.”1 The associated diagnosis must be documented by the patient’s provider.
If it is not possible to record all three components of the GCS due to the patient’s baseline, i.e. non-verbal, blind, paralyzed, assign a code from R40.244-, Other coma with partial score reported, followed by the appropriate R40.2- codes for the available eye, verbal or motor response. 2
- AHA Coding Handbook 2021
- Coding Clinic Third Quarter 2020