AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 4; Ask the Editor

Unspecified Coma

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? ...

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