Let's look at the ever-handy Glasgow Coma Scale. Capturing documentation related to the coma scale has been a useful way for us to capture otherwise missing Major Complications and Co-Morbidities in the past. The scale was initially created to document in a replicable way the mental status/neurologic functioning of a trauma patient, but in the subsequent decades, has advanced in its use to medical patients without trauma and ICU patients. Makes sense, right? And the original (read: pre-2021) ICD-10-CM Official Guidelines for Coding and Reporting captured this reality in the section that address GSC:
Chapter 18: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) . . .
e. Coma scale
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). . . .
So what changed this year? The powers that be have reversed the progression of medical practice and documentation, by eliminating the non-trauma use of this tool.
The current section reads as follows:
e. Coma scale
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury 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 codes should be sequenced after the diagnosis code(s).
We do not know why this change has occurred. Instructions for use of the GCS emphasize that one should not report for a patient with a medically induced coma or a sedated patient. Possibly the tool was being used in these patients. But regardless, be aware of the change.
We do not think this prohibits you from capturing the GCS in medical and ICU patients. It does not explicitly state that you cannot document the score in non-trauma settings. But it is an area of concern, and we will follow the issue closely.