Coding GCS
Wondering how other hospitals code GCS: using only the numeric value given or from physician documentation? Our coding department will only code if numeric value given (E:2, M:1, V:2) and not if the physician clearly documents each category.
Comments
As noted in the 2017 CDI Pocket Guide, The 2017 Official Guidelines for Coding and Reporting section I.C.18.e state that GCS can be based on non-provider (e.g. nursing) documentation including EMT pre-hospital scores. Providers do not have to document the GCS components or total score, but a condition pertinent to the GCS score must be documented.
All GCS scores recorded can be reported, but the accepted standard practice is to code the lowest GCS score which is clinically considered the most important.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
The CDI Pocket Guide available from ACDIS has a section devoted to coma and the GCS in its Key Reference diagnoses.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
It's really only a significant coding issue when severe scores are billed on a claim since those are the only ones impacting reimbursement. E 1 & 2 / V 1 & 2 / M 1,2,3.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
Is it better to code GCS from the ambulance, ER or at time of hospital admission. I am asking this because we do not always have the ambulance documentation readily available, but can create a process to get it timely, if it is more important to code from the ambulance report.
Thank You,
Leslie Berry, APRN, CCDS
You can code each component separately and more than once, if desired. I think conventional practice is for most sites the report the worst scores.
A few of my reminders would be:
1. If coma is medically-induced, do not report coma or GCS scores resulting as this expected and desired
2. In a similar fashion, a patient on a vent can't speak - do not report verbal
3. Often patients will be somnolent as an expected result of medications...In my opinion, this is also not reportable as there is no disease or disorder present, rather an expected consequence is present.
4. It may be advised to ensure a true coma is present when the GCS is scored rather than only a brief change in neurological status due to something like syncope which resolves quickly.
5. Bear in mind GCS may result in sole reporting of MCC, and as such, take care the scores and coding are supported.
These are my personal beliefs and opinions.
Paul Evans, RHIA, CCDS
I am confused by this statement. It is literally right in the official coding guidelines.
Coding Guideline 1.C.18.e “Coma Scale”
"The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition."
And in Coding clinic
...may also be used to assess the status of the central nervous system for other nontrauma conditions, for example monitoring patients in the intensive care unit regardless of the medical condition.. (paraphrased)
4th Q 2016, pg. 65 I think.
(1) OCG section 1.C.18.e and related Coding Clinic are speaking only to the type of patients from who a GCS may be used. Section I.B.14 (see below) governs the associated condition requirement. The clinical issue has been that many providers mistakenly believe that GCS is only used in trauma cases, but it is actually an essential objective measure of altered level of consciousness for "non-trauma conditions" with any "medical condition". GCS has only been validated to have prognostic and treatment implications in a trauma setting.
(2) The questions about indexed vs non-indexed "associated diagnoses made the thoroughly review and reconsider if an indexed term must be assigned to the claim, and my conclusion is it does not. The rationale is as follows:
OCG Section I.B.14 - Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale states:
“For the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider…the associated diagnosis (such as overweight, obesity, acute stroke, or pressure ulcer) must be documented by the patient’s provider.”
The only requirement is “documentation” without reference to whether an indexed code must be assigned. The “cleanest” claim would include a code for the associated diagnosis. If there is no available ICD-10 code for the associated diagnosis, an auditor will not be able to confirm it from the claim submitted and the supporting medical record information identifying the diagnosis would then have to be submitted on appeal to the auditor.
Indexed diagnoses commonly associated with an altered level of consciousness include lethargy, stupor, coma and unconsciousness. Two frequently used clinical descriptions that are not indexed (but need to be) and have no assignable ICD-10 codes are obtunded/obtundation and unresponsive/ unresponsiveness which are similar in nature to stupor where they could be classified.
We plan to add this clarification to the 2019 CDI Pocket Guide.
(3) With reference to the October question about what and how many GCS scores to code. The clinical convention in trauma is to classify the severity of coma on the basis of the lowest score recorded at any time including pre-arrival. For coding purposes, it seems most appropriate to code the lowest score recorded at the time of admission or subsequently. In the absence of another recorded GCS at the time of admission, it seems reasonable to code the EMS GCS if it is lower than any subsequent GCS.
Of course, codes for GCS scores can be assigned as many times as desired but that's a bit impractical unless there is a requirement to do so - perhaps trauma center data reporting has some specifications?
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
Unfortunately, "unresponsive" does not code to anything. "Unconscious" codes to R4020 Unspecified coma. You can take a look at nursing documentation perhaps, if you don't have access to the EMS run sheet.