Coma R40.20, Is this appropriate for final coding and reporting without TBI?
Recently during audit and collaboration with my team of Coding Professionals regarding a finding of missed documentation r/t Dx Coma POA R4020 with identified impact to SOI, ROM, and expected mortality. The coding professional did not support finding with rationale:
The coma scale codes (R40.2-, Coma) can only be used in combination with traumatic brain injury codes, thus, not appropriate for this encounter. This is a coding guideline not a clinical guideline. As such, this guidance isn’t meant for clinical dx of a patient, rather, how to report the ICD-10-CM codes.
Based on the update to the coding guidelines on October 1, 2020 my understanding is a limitation of the GCS/Coma scale codes requiring a TBI for accurate final coding and reporting and not R4020 Coma, unspecified.
I'm curious how other facilities capture and report R4020 Coma, unspecified with the current perspective set with our department that it is only reportable with TBI. I really want to dive into the accurate capture and reporting of Coma on those cases that do not have a TBI....clinically I am having a hard time accepting that we are unable to accurately report the pts SOI and ROM to include Coma for those cases without TBI. In addition, a need for clarification and understanding to assure we are doing the right thing and accurately reporting the resource consumption, true clinical picture of patients SOI/ROM, hard work, and quality care provided.
In my research findings also surfaced a DRG for Non-traumatic w/Coma...this would contradict the guideline if it is meant to encompass R4020....
Thoughts, please? Thanks for your feedback, support, guidance, and time :)