Q: How many times should Glasgow Coma Scale information be captured? If you have the ambulance, ED physician, and attending physician all recording the score, should each be reported?
A: The score should be reported as often as the physician determines it is necessary. In ICD-10-CM, the seventh character of the codes used to report the results of the testing explain where and when the data is captured:
- 1, In the field (EMT or ambulance)
- 2, at arrival to the ED
- 3, at hospital admission
- 4, 24 hours or more after hospital admission
If it’s unknown when the data was captured, use seventh character 0 (unspecified time).
Editor’s note: Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Florida, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at [email protected].
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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