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Using Glasgow Coma S core in a Head I njury, Stroke & E ncephalopathy

This case study discusses the use of Glasgow Coma Score (GCS) in a patient admitted for sepsis and developing encephalopathy and CO2 Narcosis. The impact of accurate coding and documentation on severity of illness (SOI) and risk of mortality (ROM) is highlighted.

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Using Glasgow Coma S core in a Head I njury, Stroke & E ncephalopathy

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  1. Using Glasgow Coma Score in aHead Injury, Stroke & Encephalopathy Nicole Schultz, RN - ORMC 3/26/2018

  2. Case Study • Summary: 61 y/o female with intractable headache and pain around right eye admitted for sepsis 2/2 herpes zoster, developed encephalopathy and CO2 Narcosis, acute hypercapnic hypoxic resp failure, transferred to MICU when stable discharged to acute rehab. Sepsis was ruled out and this left us with: • PdxB02.30 Zoster Ocular Disease and DRG 124 w/MCC LOS 3.6 RW 1.2489, Documentation in the chart: • 2/22 RN notes GCS eyes 2, verbal 1, motor 4: total 7 • 2/22 Nephrology Consult: Acute Encephalopathy/CO2 Narcosis” • CDI coded: GCS 2 eyes: R40.2124 (MCC and HCC) & GCS 4 motor: R40.2344 (MCC and HCC) Opportunity: To increase the SOI/ROM and greater specificity through the addition of the GCS codes. Impact: This raised our SOI/ROM from a 6 to an 8.

  3. CDI Tip Book page 80: https://acdis.org/system/files/resources/ACDIS-Radio-slides-Mar162016-coma-program.pdf

  4. Coding Guideline:

  5. Coding Clinic-list quarter, year and page # ICD-10-CM/PCS Coding Clinic, Second Quarter ICD-10 2015 Pages: 17-18 Effective with discharges: July 6, 2015 Title of Coding Clinic: Effective with discharges • Question: Can individual Glasgow coma score (GCS) codes be assigned based on documented numeric values rather than the description of the codes (e.g., eyes open to pain, best verbal response, etc.)? • When reporting the GCS, can a total score be calculated if only individual scores are documented? • Answer: Yes, if the provider's documentation clearly shows that the ratings are specific scores or numeric values for the Glasgow scale, it would be appropriate to report codes from categories R40.21-, R40.22- and R40.23-. These codes are used only when the individual score(s) or numeric values are documented within the health record. • Do not assign code R40.24-, Glasgow coma scale, total score, if the individual scores are documented. Assign code R40.24-, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s). The 7th character indicates when the scale was recorded. The 7th character should match for all three codes. Okay to break up into two pages if long

  6. Thank You • kseekircher@nwhc.net

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