Glasgow Coma Score in Head Injury, Stroke & Encephalopathy
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Nicole Schultz, RN - ORMC
3/26/2018
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:
•
Pdx B02.30 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.
CDI Tip Book page 80:
https://acdis.org/system/files/resources/ACDIS-Radio-slides-Mar162016-coma-program.pdf
Coding Guideline:
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
January 18, 2018
7
Thank You
kseekircher@nwhc.net
A 61-year-old female with intractable headache and eye pain was admitted for sepsis secondary to herpes zoster, leading to encephalopathy and CO2 Narcosis. Through accurate Glasgow Coma Score (GCS) documentation, the Severity of Illness (SOI) and Risk of Mortality (ROM) were improved. Coding guidelines and CDI tips were followed to enhance specificity and coding accuracy in the case.
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Presentation Transcript
Using Glasgow Coma Score in a Using Glasgow Coma Score in a Head Injury, Stroke & Encephalopathy Head Injury, Stroke & Encephalopathy Nicole Schultz, RN - ORMC 3/26/2018
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: Pdx B02.30 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.
CDI Tip Book page 80: https://acdis.org/system/files/resources/ACDIS-Radio-slides-Mar162016-coma-program.pdf
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
Thank You kseekircher@nwhc.net January 18, 2018 7
