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

  • Krista:  There ought to be a GCS scoring form in the record somewhere.  The numeric values for E/M/V as just a short-hand  method of summarizing the individual component scores taken from the scoring form,  and the form really should be in the medical record to validate the scores.

    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


  • Also, only the component scores are coded, not the total score.

    Richard D. Pinson, MD, FACP, CCS
    Pinson & Tang
    CDI Educators and Advisers
    Authors of the CDI Pocket Guide
    www.pinsonandtang.com

  • What diagnosis does your coders have to see before accepting the GCS scores as MCCs? For example, CVA or head injuries are widely accepted but what about Encephalopathy, Unconsciousness, or other vague alterations in mental status without a specific etiology documented or known?
  • Anything that indicates an alteration in level of consciousness and responsiveness.  Common ones might be encephalopathy, confusion, altered mental status, lethargy, drowsiness, obtundation, stuporous any description of decreased responsiveness, an intracranial process (e.g. trauma, hemorrhage, CVA, brain tumor), 

    The term “unconsciousness” is classified by ICD-10-CM and coded as coma (MCC), but must be a clinically validated as a comatose state representing a persistent (not transient) state of altered level of consciousness. Brief loss of consciousness may be nothing more than a symptom intrinsic to some relatively minor condition such as a seizure, syncope, or concussion and in these and similar situations it should not be coded.

    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

  • Are  the GCS components only scored if it is permanent or lasting. For instance if a patient arrives to the ER and they are documented as a 1 or 2,  but improve during the stay, can they still be coded?
  • GCS can be coded it there is a persistent state of altered level of consciousness and unresponsiveness. It certainly can be coded when there is improvement but some continuing alteration would be expected. One wouldn't expect a quick recovery to normal to be consistent with significant degrees of coma. There are no absolute guidelines for duration required - depends on circumstances and sometimes a difficult subjective call.

    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

  • I usually suggest to people that you should at least capture upon arrival, upon admission and then any that describe a very significant change. the ambulance report many time is useful to again offer support related to applied diagnoses and the patient's presenting condition. i find many though, do not have easy access to EMT documentation. 
  • Can we code GCS more than once? Can we code in each area?
  • 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

  • Thank you very much. This helps a lot.
  • GCS can be coded it there is a persistent state of altered level of consciousness and unresponsiveness. It certainly can be coded when there is improvement but some continuing alteration would be expected. One wouldn't expect a quick recovery to normal to be consistent with significant degrees of coma. There are no absolute guidelines for duration required - depends on circumstances and sometimes a difficult subjective call.

    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 there any coding guidance that states that ANY associated documented diagnosis (even if not indexed), such as unresponsive (provided its not an expected finding, or inherent (syncope/seizure)) is sufficient to code the GCS.  We are getting pushback from coding that since unresponsive is not indexed, the GCS can not be captured.  Our ACDIS pocket guides states 'associated dx, such as unresponsive, stupor, obtundation, comatose" but not all these are indexed in the coding book. Can anyone help?
  • edited February 2018
    GCS can be coded it there is a persistent state of altered level of consciousness and unresponsiveness. It certainly can be coded when there is improvement but some continuing alteration would be expected. One wouldn't expect a quick recovery to normal to be consistent with significant degrees of coma. There are no absolute guidelines for duration required - depends on circumstances and sometimes a difficult subjective call.

    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 there any coding guidance that states that ANY associated documented diagnosis (even if not indexed), such as unresponsive (provided its not an expected finding, or inherent (syncope/seizure)) is sufficient to code the GCS.  We are getting pushback from coding that since unresponsive is not indexed, the GCS can not be captured.  Our ACDIS pocket guides states 'associated dx, such as unresponsive, stupor, obtundation, comatose" but not all these are indexed in the coding book. Can anyone help?





    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.

  • afrady@blr.com oh my gosh....those words were right in front of our eyes. I have personally read them over and over and with our coding department focusing in on the concept of a dx that is NOT indexed was driving me crazy.   I want to THANK YOU for high lighting those words.
  • I apologize from me long absence. I have a couple of comments about Feb string.

    (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

  • If "unresponsive" is documented in ER but the GCS isn't. How do we code this. Can we code a E1, V1, M1? Or does the term unresponsive just allow us to code the GCS it is documented?
  • I understand this question is from last year, however I will add my 2 cents.

    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.
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