Documentation of Coma by MD in the NIH Stroke Scale Assessment

mayraluciano16@gmail.com

If a patient is found unresponsive at home, and the ED physician documents coma in the NIH Stroke Scale (LOC=coma=3), can coma be coded? Or is a query still needed for the documentation of coma, unconsciousness, or vegetative state. 
Please note, the GCS individual component values were documented by EMS and the ED Triage RN and the total scores were equal or less than 8.
The patient was admitted for Acute cerebral infarct and expired within 4 days of admission.

Thank you in advance.

mycdi

Yes NIH stroke scale can be coded from and GCS score will also be coded as per new Guidelines. But if Individual values are available they will be coded first per code guidelines.  This can be problematic if you need  UHC variable as total score code is not in the variable list. Per guidelines  CDS must code the individual scores first. It also states that more than one score can be given. If there is a total score less than 24 hours ( 7th character of the code is time) available they can also code that as well and will still count as POA. talk to your CDS and ask them to consider also a second score for UHC as total score.

mayraluciano16@gmail.com

mycdi said:

Yes NIH stroke scale can be coded from and GCS score will also be coded as per new Guidelines. But if Individual values are available they will be coded first per code guidelines.  This can be problematic if you need  UHC variable as total score code is not in the variable list. Per guidelines  CDS must code the individual scores first. It also states that more than one score can be given. If there is a total score less than 24 hours ( 7th character of the code is time) available they can also code that as well and will still count as POA. talk to your CDS and ask them to consider also a second score for UHC as total score.

Thank you. 
So the diagnosis coma can be coded from the NIH scale if documented by the physician?