GCS excludes
Hi all,
I have mortality chart that I am reviewing where we have a severe truama. Head injury, spinal cord injury with quadriplegia, resp failure, etc. I advised that we should be coding the individual GCS scores available in the record: : eye opening response no response = 1, motor response postures with arm extension = 2, verbal response mute = 1, total score 4. The coder got back with me saying there was an excludes note when she tried:
[cid:image001.png@01D15F3F.5E155610]
This is suggesting that this GCS cannot be coded with things like nicotine dependence, anxiety, and PTSD???? The guidance also that we can code both if they are not related to eachother, of course they are not.
So should we code the GCS?? I think we should but I want to make sure before I discuss further with coding.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I have mortality chart that I am reviewing where we have a severe truama. Head injury, spinal cord injury with quadriplegia, resp failure, etc. I advised that we should be coding the individual GCS scores available in the record: : eye opening response no response = 1, motor response postures with arm extension = 2, verbal response mute = 1, total score 4. The coder got back with me saying there was an excludes note when she tried:
[cid:image001.png@01D15F3F.5E155610]
This is suggesting that this GCS cannot be coded with things like nicotine dependence, anxiety, and PTSD???? The guidance also that we can code both if they are not related to eachother, of course they are not.
So should we code the GCS?? I think we should but I want to make sure before I discuss further with coding.
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
Interim Coding Advice on Excludes 1
Coding Clinic, Fourth Quarter ICD-10 2015 Page: 40 Effective with discharges: November 13, 2015
Related Information
The National Center for Health Statistics (NCHS), the Federal agency responsible for use of the ICD-10-CM in the United States, has issued interim advice as it pertains to excludes 1 notes and unrelated conditions. The following information can be found on the NCHS website: http://www.cdc.gov/ nchs/data/icd/Interim_Coding_advice_on_Excludes_1_note.pdf.
There are circumstances that have been identified where some conditions included in Excludes1 notes should be allowed to both be coded, and thus might be more appropriate for an Excludes2 note. However, due to the partial code freeze, no changes to Excludes notes or revisions to the official coding guidelines can be made until October 1, 2016. The new guidance concerning Excludes1 notes is intended to allow conditions to be reported together when appropriate even though they may currently be subject to an Excludes1 note.
Interpretation of Excludes1 Notes
Coding Clinic, Fourth Quarter ICD-10 2015 Page: 40 Effective with discharges: November 13, 2015
Related Information
Question:
We have received several questions regarding the interpretation of Excludes1 notes in ICD-10-CM when the conditions are unrelated to one another.
Answer:
If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes1 note. For example, the Excludes1 note at code range R40-R46, states that symptoms and signs constituting part of a pattern of mental disorder (F01-F99) cannot be assigned with the R40-R46 codes. However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and the mental disorder.
In another example, code range I60-I69 (Cerebrovascular Diseases) has an Excludes1 note for traumatic intracranial hemorrhage (S06.-). Codes in I60-I69 should not be used for a diagnosis of traumatic intracranial hemorrhage. However, if the patient has both a current traumatic intracranial hemorrhage and sequela from a previous stroke, then it would be appropriate to assign both a code from S06- and I69-.
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I am looking for some "official guidance" on when to use the coma scale codes.
Thanks,
Suzonne Bourque, RHIA, CCS, CCDS
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, February 04, 2016 12:03 PM
To: Kathryn Good
Subject: re:[cdi_talk] GCS excludes
In going through the R40 series, there are Excludes notes throughout which might distract the coders. The one that says when it is part of a mental disorder, you don't code it. The thing is that when it is NOT part of mental disorder, you code first the trauma and then the GCS score period. It does not say anything about existing concomitantly with a psychological disorder - it says when it is PART OF the psychological disorder. The documentation in a chart that the patient has one of the psychological disorders as a historical condition certainly does not make a link to restrain a coder from assigning the code in a trauma patient.
Dr. G.
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Coma scale
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).
These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores.
Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Suzonne
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, February 24, 2016 3:55 PM
To: Bourque, Suzonne
Subject: RE: re:[cdi_talk] GCS excludes
The official guidance says to use it with head injuries and CVA's.
Coma scale
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).
These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes.
At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores.
Assign code R40.24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s).
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, February 24, 2016 2:47 PM
To: Kathryn Good
Subject: RE: re:[cdi_talk] GCS excludes
Does a patient have to have a diagnosis of "coma" (diabetic, hepatic, coma due to trauma) to use a code from the Glascow coma scale? What if the pt comes in with altered mental status and a glascow coma score is documented?
I am looking for some "official guidance" on when to use the coma scale codes.
Thanks,
Suzonne Bourque, RHIA, CCS, CCDS
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, February 04, 2016 1:21 PM
To: Bourque, Suzonne
Subject: RE: re:[cdi_talk] GCS excludes
Thanks!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404
-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Thursday, February 04, 2016 12:03 PM
To: Kathryn Good
Subject: re:[cdi_talk] GCS excludes
In going through the R40 series, there are Excludes notes throughout which might distract the coders. The one that says when it is part of a mental disorder, you don't code it. The thing is that when it is NOT part of mental disorder, you code first the trauma and then the GCS score period. It does not say anything about existing concomitantly with a psychological disorder - it says when it is PART OF the psychological disorder. The documentation in a chart that the patient has one of the psychological disorders as a historical condition certainly does not make a link to restrain a coder from assigning the code in a trauma patient.
Dr. G.
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: kathryn.good@nahealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12649561.a6bbaf3538c19e934e5136fbd051a6b1@hcprotalk.com
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923 This message has been scanned and no issues were detected.
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Copyright 2013
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: kathryn.good@nahealth.com If you would like to be removed from CDI Talk, please send a blank email to leave-cdi_talk-12649561.a6bbaf3538c19e934e5136fbd051a6b1@hcprotalk.com
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923This message has been scanned and no issues were detected.
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To report this email as SPAM, please forward it to spam@websense.com
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CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
You are receiving this message as a member of CDI Talk as: sbourque@wkhs.com
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923