Cracking the Code

Updated Glasgow Coma Scale Guidance for FY2021

For FY2021 ICD-10-CM Official Guidelines for Coding and Reporting, CMS revised the guideline for the Glasgow Coma Scale (GCS). Per the updated guidance, “The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes. These codes are primarily use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s).”

Per the updated guidelines, the GCS score will NO longer be applicable to acute cerebrovascular disease or sequelae of cerebrovascular disease codes starting with October 1st, 2020 discharges. Furthermore, the GCS score may NOT also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.

There may be further clarification with this updated guidance in the AHA Coding Clinic for Fourth Quarter 2020. However, for now, these are the official updated guidelines for GCS score.

Reference: Reference: ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.18.e: Coma scale
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