Glascow Coma Scale in Chronic Conditions

Coonan6@gmail.com

I looked back through the forum and this topic hasn't been discussed for awhile.  I recently coded the glascow coma scale on a patient that had their GCS evaluated several times during his hospitalization. The patient had severe intellectual disabilities and cerebral palsy. He was admitted for aspiration pneumonia and hypoxia. The coder wouldn't code the GCS scale because she didn't feel that there was a diagnosis that correlated to the GCS scale.  I had 2 MCC's on the chart from the individual glascow coma scale. I couldn't find any excludes 1 notes on the coding of the GCS. His GCS scores changed during the hospitalization from a low of 8 to a high of 14.  The chart was sent for a second level review and IP coding answered that the documented GCS scale didn't give an accurate account of improvement because some of his issues may be due to his severe intellectual disability. I would appreciate any feedback and/or resources to support or not support the coding of the GCS score for chronic conditions. 

(I did share in the emails back and forth that the GCS can be captured for any medical condition.  Coding feels that it has to be an acute condition)

Thank You
Theresa Coonan BSN, RN, CCDS

vparent@emhs.org

Glasgow coma scale

      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-):

	0	-	unspecified time
	1	-	in the field [EMT or ambulance]
	2	-	at arrival to emergency department
	3	-	at hospital admission
	4	-	24 hours or more after hospital admission

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.

 Most of the studies I looked at excluded cerebral palsy patients unless there was a new TBI. If a component of the GCS cannot be adequately addressed such as with paralysis or non-verbal status, it is not valid and should be documented as such. Was the patient experiencing altered levels of consciousness? or was the GCS more of a baseline? with a change of 8-14, suggests acute process but again, is the patient paralyzed or non-verbal? I guess I would want to know in what ways the score of 8-14 changed?

Possible considerations would be encephalopathy, sepsis, acute respiratory failure?

lberry@wcch.com

We have a designated GCS in the ER notes. If the patient is scored there on eye opening and speech but not for motor, can we use the description in the narrative to score them? For instance if eye opening is scored 4 and verbal response 2 but nothing in the motor. In the narrative the physician documented moves on command, can we code this? 
Thank you