AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2020 Issue 3; Ask the Editor

Partial Glasgow Coma Score

A non-verbal 65-year-old male, who has cerebral palsy and an intellectual disability, presents to the emergency department with a traumatic head injury after falling and striking his head on the sidewalk. The patient was witnessed with loss of consciousness for approximately two minutes and on admission he appeared lethargic and drowsy. While completing the Glasgow coma scale, the provider evaluated eye opening and motor response; however, since the patient was non-verbal at baseline, the best verbal response could not be assessed. What is the appropriate code assignment for the Glasgow coma scale score? Is it appropriate to assign code R40.244-, Other coma, without documented Glasgow coma scale score, or with partial score reported, since the best verbal response could not be assessed? ...

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