The Official Guidelines for Coding and Reporting section I.C.18.e. was revised effective October 1, 2020 to indicate that coma scale codes are to be used only in conjunction with traumatic brain injuries (TBI). Subcategory R40.2, Coma, was provided as the code range in this guideline, which includes code R40.20, Coma, unspecified. However, the coma scale codes start at subcategory R40.21, Coma scale, eyes open, and code R40.20 does not appear to capture any coma scale score information. Would code R40.20 be reported with non-traumatic brain injury conditions, such as intracerebral hemorrhage or stroke, when the patient is also in a coma?
Yes, it would be appropriate to report code R40.20, Coma, unspecified, with non-TBI conditions when the patient is also comatose. The intent of the coma guideline revision was to indicate that coma scale score codes should only be reported with traumatic brain injuries. Code R40.20 does not fall into the coma scale score code range. Therefore, assign code R40.20, when coma is documented and reporting requirements have been met.
The Official Guidelines for Coding and Reporting section I.C.18.e. has been revised to clear up any confusion as follows:
“Code R40.20, Unspecified coma, may be assigned in conjunction with codes for any medical condition.”