AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2014 Issue 1; Ask the Editor
Glasgow Coma Score
ICD-10-CM provides codes to identify the Glasgow coma scale (GCS) score. When the patient presents with a traumatic brain injury (TBI), these codes are used in conjunction with the specific codes describing the TBI. If the emergency medical technician (EMT) documents the patient’s initial GCS score in the field, can the EMT’s documentation be used? Coders are concerned that there is no official advice or guideline that allows use of nonphysician documentation for the Glasgow coma scores. These scores are typically documented by personnel other than physicians. What documentation can be used for determining the ICD-10-CM Glasgow coma score code? ...
Subscribe or sign in to view the full article.
Article Overview
This article addresses how Glasgow Coma Scale information is documented and interpreted for ICD-10-CM reporting, especially when traumatic brain injury is also present. It focuses on the role of pre-hospital and other nonphysician documentation, making it relevant for coders, emergency care teams, and documentation staff who need to understand what sources may support coding decisions.
Why This Topic Matters
Accurate handling of Glasgow Coma Scale documentation affects how injury-related records are reported and supported in the medical record. The topic is important for coding professionals who must determine whether available clinical documentation is sufficient for ICD-10-CM reporting.
What You Will Learn
- How the article frames Glasgow Coma Scale documentation for ICD-10-CM reporting
- What kinds of documentation sources are discussed for determining the score
- Why traumatic brain injury encounters are relevant to this topic
- How the article approaches documentation from nonphysician sources
Who Should Read This
- Medical coders
- Coding auditors
- Emergency department documentation staff
- Trauma registry staff
- Clinical documentation improvement professionals
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com