Coding GCS from physical exam

lberry@wcch.comlberry@wcch.com
in Clinical & Coding
We have a designated place to document GCS in the ER record. 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 the nurse failed to score motor but  In the narrative (physical exam) the physician documented "moves on command", can we code this? 
Thank you

Comments

  • allenfrx@gmail.comallenfrx@gmail.com
    edited April 2020
    The only place in all of coding guidance that I can even think of that would be similiar was the guidance that coders could code Gustilo Anderson Grades I and II from the description but not IIIs.  Or maybe the allowance of reporting Heart failure based on HFrEF  vs HFpEF.

    In general though..the answer to your question would be no.   Guidance says that code assignment is only based on "provider documentation".    

    The GSC gets confusing as those CAN be taken by non-provider clinicians, but in the example you gave, you are not taking it from a documentation of the score you are extrapolating it from their description of the patient (effectively scoring it yourself).
  • lberry@wcch.comlberry@wcch.com
    Yes, I understand
    Thank you very much. 
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