2025 ICD-10-CM code R40.2350
Coma scale, best motor response, localizes pain, unspecified time.
Medical necessity for this code is established by the clinical need to evaluate and monitor a patient's neurological status. The GCS score provides critical information for decision-making in managing acute neurological conditions.
Clinicians use this code to document a patient's level of consciousness, usually following trauma or other neurological events. Proper documentation of the GCS score and its components is crucial for patient management and outcomes assessment.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R40-R46
In simple words: This code describes a person's reduced level of consciousness where they respond to pain by trying to move away from it. The exact time of when this observation was made is not specified.
This code signifies a patient's level of consciousness using the Glasgow Coma Scale (GCS), where the best motor response is localizing to pain at an unspecified time.The GCS assesses eye opening, verbal response, and motor response, providing a score indicative of coma severity. Localizing to pain means the patient attempts to remove or push away a painful stimulus. The "unspecified time" indicates the assessment time is not documented as "in the field", "at arrival to emergency department", "at hospital admission", or "24 hours or more after hospital admission."
Example 1: A patient arrives at the emergency department after a motor vehicle accident. They respond to a painful stimulus by attempting to push it away. The time of this observation is not documented with more specificity than "unspecified time," so R40.2350 is used., A patient in the intensive care unit (ICU), intubated and sedated, demonstrates localization to pain during a neurological examination at an unspecified time. R40.2350 is used., A patient brought to the hospital by EMS for altered mental status localizes to pain. The EMS documentation specifies localizing to pain but does not document any specific times and no documentation is added during transport of care, so R40.2350 would apply.
Documentation should include the details of the GCS assessment, including eye opening, verbal response, and motor response scores. The specific stimulus used to elicit the motor response and the patient's reaction should be clearly noted.
** Excludes1: neonatal coma (P91.5), somnolence, stupor and coma in diabetes (E08-E13), somnolence, stupor and coma in hepatic failure (K72.-), somnolence, stupor and coma in hypoglycemia (nondiabetic) (E15). Excludes2: abnormal findings on antenatal screening of mother (O28.-), certain conditions originating in the perinatal period (P04-P96), signs and symptoms classified in the body system chapters, signs and symptoms of breast (N63, N64.5).
- Specialties:Emergency Medicine, Critical Care, Neurology, Trauma Surgery
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Ambulance - Land