A one-year delay of the implementation of ICD-10-CM and ICD-10-PCS has been approved, pushing the implementation date from Oct. 1, 2013 to Oct. 1, 2014. This provides additional time to become familiar with the ICD-10-CM code set and the additional information and specificity included therein.

Available ICD-10 codes will provide information on measurement scales that could not be reported with ICD-9-CM. The transition to ICD-10-CM will be easier for those coders who take the time to learn about the information reflected in these measurement scales and how the scales are represented by ICD-10-CM codes. One of the measurement scales that inpatient rehabilitation facility (IRF) coders will want to understand involves codes that report the Glasgow Coma Scale scores.

Glasgow Coma Scale

Documentation in IRF medical records often includes coma scale scores for patients with traumatic brain injuries, cerebrovascular disease or sequelae of cerebrovascular disease. This information cannot be captured by ICD-9-CM. If a coder does not know that ICD-10-CM codes are available to report details about a coma, the codes will not be assigned. A code for the diagnosis is reported first, and code R40.2- should be added to report the score that determines the level of central nervous system damage or injury, further indicating whether a patient is conscious or comatose.

When detailed information about the coma is unknown, code R40.20, unspecified coma, should be assigned.

The Glasgow Coma Scale includes three tests used to report criteria such as open eyes, verbal responses and motor responses. When individual scores for these three items are documented, ICD-10-CM codes should be assigned and reported. There are four scores for eyes, five for verbal response and six for motor response. The scores for each subcategory start with 1 for the greatest impairment (never or none) and are assigned sequentially, with the highest number assigned for the best performance. The best score in each subcategory is reported. An ICD-10-CM code is available to report each of the scores included in the scale. To complete the scale, a code from each subcategory must be reported.

R40.21 Coma scale, eyes open

R40.211 Coma scale, eyes open, never

R40.212 Coma scale, eyes open, to pain

R40.213 Coma scale, eyes open, to sound

R40.214 Coma scale, eyes open, spontaneous

R40.22 Coma scale, best verbal response

R40.221 Coma scale, best verbal response, none

R40.222 Coma scale, best verbal response, incomprehensible words

R40.223 Coma scale, best verbal response, inappropriate words

R40.224 Coma scale, best verbal response, confused conversation

R40.225 Coma scale, best verbal response, oriented

R40.23 Coma scale, best motor response

R40.231 Coma scale, best motor response, none

R40.232 Coma scale, best motor response, extension

R40.233 Coma scale, best motor response, abnormal

R40.234 Coma scale, best motor response, flexion withdrawal

R40.235 Coma scale, best motor response, localizes pain

R40.236 Coma scale, best motor response, obeys commands

A seventh character is added to each code from subcategories R40.21-, R40.22- and R40.23- to report when the scale was applied. The seventh character should be the same for each of the three codes. If the scale is scored multiple times during an IRF admission, the codes could be reported more than once. The seventh characters are as follows:

  1. Unspecified time

  2. In the field (EMT or ambulance)

  3. At arrival to emergency department

  4. At hospital admission

  5. 24 hours or more after hospital admission

The total score is not reported when the individual scores are documented. If the individual scores are not documented and the total score is documented, report code R40.24 for Glasgow Coma Scale, total score. Patients with a total score of 3-8 are considered to be in a coma. Patients with total scores of 9 or higher are not in a coma. Subcategory codes are available for the total scores:

R40.241 Glasgow Coma Scale score 13-15

R40.242 Glasgow Coma Scale score 9-12

R40.243 Glasgow Coma Scale score 3-8

When a Glasgow Coma Scale score is not documented, or when only a partial score is reported, assign code R40.244, other coma.

Example: The patient was admitted to the IRF following a two-week stay at the acute-care hospital for treatment of a traumatic brain injury (TBI) after a fall from a ladder. On the fifth day after admission to the IRF, the Glasgow Coma Scale test was scored as:

Eyes open: 2 R40.2124

Verbal response: 3 R40.2234

Motor response: 2 R40.2324

The eyes-open response score of 2 indicates that the eyes opened to pain; the verbal response score of 3 indicates the best verbal response was inappropriate words; the motor response score of 2 indicates the best motor response was extension. The seventh character assigned is 4 to indicate that the score was obtained 24 hours or more after hospital admission.

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience. As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH). Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).

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