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?    ...

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