RE: [EXTERNAL] re:coding from nursing documentation
GCS of course is new because we didn't code it in ICD-9.
Glasgow coma score
Coding Clinic, First Quarter ICD-10 2014 Pages: 19-20 Effective with discharges: March 31, 2014
Question:
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?
Answer:
It would be appropriate to use the pre-hospital report containing the EMT’s documentation, and other nonphysician documentation to determine the Glasgow coma score.
Glasgow coma score
Coding Clinic, First Quarter ICD-10 2014 Pages: 19-20 Effective with discharges: March 31, 2014
Question:
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?
Answer:
It would be appropriate to use the pre-hospital report containing the EMT’s documentation, and other nonphysician documentation to determine the Glasgow coma score.