GCS
Do you capture GCS in a chronic neurologically devastated patient? Ex.11yr old with HIE at birth with no change in neuro status during hospitalization?
Do you capture GCS in a chronic neurologically devastated patient? Ex.11yr old with HIE at birth with no change in neuro status during hospitalization?
Comments
I see no reason not to do so.
We generally do not but I guess there's nothing that would prohibit you from doing so. I pulled the Coding Clinic for reference. It suggests that the codes can be assigned for monitoring a patient in the ICU regardless of medical condition. I guess some auditors could try to fight on that but no reason to be shy of coding something that's legitimate in fear of auditors. I have always thought of the GCS to be used with more acute conditions and interested to hear what others have to say.
ICD-10-CM
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Pages: 64-65 Effective with discharges: October 1, 2016
Related Information
Subcategory R40.24-, Glasgow coma scale, total score, will require a 7th character to indicate when the scale was recorded. The 7th characters are similar to those already in existence for the Glasgow coma scale individual scores (R40.21- to R40.23-):
A code from subcategory R40.24 should be assigned when only the total coma score is documented.
In addition, the ICD-10-CM Official Guidelines for Coding and Reporting have been revised so that the coma scale codes 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. Prior to this change, the Official Coding Guidelines specified that the coma scale codes (R40.2-) could only be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes.
In addition, the ICD-10-CM Official Guidelines for Coding and Reporting have been revised so that the coma scale codes 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. Prior to this change, the Official Coding Guidelines specified that the coma scale codes (R40.2-) could only be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes.
"Key Statement"
"monitoring of patients regardless of the medical condition'
The Guidelines permit reporting of GCS in conjunction with the late effects of CV disease codes. As such, it is permissible to assign them in this this situation.
Reference:
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 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. The coma scale codes should be sequenced after the diagnosis code(s).