There has been some confusion around updates related to the Glasgow Coma Scale (GCS) codes. Changes affecting GCS, though not clearly explicit but certainly significant, were made in the recent updates to the FY2021 ICD-10-CM Official Guidelines for Coding and Reporting.
With multiple accounts of a lack of clarity around these changes, there have been discussions of additional specific guidance to be offered in the future, though no specifics given. Essentially, the revised guideline is designed to prohibit GCS reporting in non-trauma.
Within the context of the changes, the GCS codes have been revised to refer only to trauma cases and should be used in conjunction with traumatic brain injury codes, beginning with discharges on October 1, 2020. Among the revisions for FY 2021, I.C.18.e was revised, with a new update to read: "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."
Essentially, the revised guideline is designed to prohibit GCS reporting in non-trauma. With multiple accounts of a lack of clarity around these changes, there have been discussions of additional specific guidance to be offered in the future, though no specifics given.
The GCS consists of three items (components): eye (scored 1 to 4), verbal (scored 1 to 5), and motor (scored 1 to 6). Scores on each of these components are added to obtain the total Glasgow Coma Scale (GCS) score, ranging from 3 to 15. As outlined in the guidelines, at a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores.
It is essential to review the GCS score documentation to determine the level of care the patient should receive or the areas to which they should be evaluated, monitored, or treated within a facility. Ensure proper training and education on these changes to confirm medical coders are assigning the appropriate ICD-10-CM codes based on the updated coding guidelines. Regardless of the clarity provided, the updated guidelines are in place, and education is critical to prevent interruptions in revenue and workflow.
The FY 2021 ICD-10-CM Official Coding Guidelines are available for download on the CDC’s website.