HCPro, JustCoding Outpatient - 2015 Issue 46 (December)
Q&A: Recording Glasgow Coma Scale scores
December 9th, 2015
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Article Overview
This article answers a coding documentation question about Glasgow Coma Scale reporting in ICD-10-CM. It explains the general context for recording the assessment across multiple care settings and highlights the time-related reporting framework that affects how the results are captured. It is relevant to coders, billers, and clinical documentation staff working with trauma, emergency, and inpatient records.
Why This Topic Matters
Glasgow Coma Scale reporting can vary by care setting and timing, so understanding the documentation framework helps ensure consistent coding and record abstraction. The article is useful for professionals who need to interpret how the assessment is recorded in ambulance, emergency department, and inpatient documentation.
What You Will Learn
- How Glasgow Coma Scale information is discussed in relation to coding documentation
- How the timing of recorded assessment data is framed in ICD-10-CM
- Why multiple care settings may each contain relevant documentation
- How unspecified timing is handled at a high level in the reporting framework
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Billers
- Emergency department documentation staff
- Inpatient coding staff
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