2025 ICD-10-CM code R40.2353
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46) Chapter 17: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Coma scale: best motor response, localizes pain, at hospital admission.
No specific modifiers are typically associated with this code, but depending on the context, modifiers for place of service or other circumstances might be applicable.
Medical necessity is established by the presence of a coma requiring neurological evaluation. The documentation must support the clinical indication for assessment and the severity of the condition.
Neurological examination and assessment of coma severity.The physician or qualified healthcare professional determines the level of responsiveness and documents the findings using standardized scales like the Glasgow Coma Scale.
- Chapter 17: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R40-R46: Symptoms and signs involving cognition, perception, emotional state and behavior
In simple words: This code describes a medical evaluation of a person in a coma.The doctor checks how the patient responds to pain; in this case, the patient shows they can feel the pain by moving towards it. This assessment is done when the person first arrives at the hospital.
This code signifies the assessment of a patient's motor response during a coma, specifically indicating that the patient's best motor response is localization to pain upon admission to the hospital.The Glasgow Coma Scale (GCS) is often used for this assessment, but this code only reflects the motor response component.The code does not include other aspects of the GCS, such as eye opening or verbal response.
Example 1: A patient is admitted to the emergency department after a motor vehicle accident. Upon neurological examination, their best motor response is localization to pain.Code R40.2353 is used to document this finding., A patient presents to the hospital with altered mental status and suspected drug overdose.Their neurological assessment reveals localization to pain as their best motor response. Code R40.2353 is appropriate for billing., A patient is admitted to the ICU following a stroke. Neurological examination reveals that their best motor response is localization to painful stimuli.This observation is coded with R40.2353 upon hospital admission.
Complete neurological examination including documentation of Glasgow Coma Scale (GCS) scores or other relevant coma scale, if used;patient's response to painful stimuli must be specified as 'localizes' and the time of assessment (at hospital admission) must be clearly stated in the medical record. Supporting documentation should include the circumstances leading to the coma.
** This code is highly specific and requires careful attention to detail during documentation.The timing of the assessment ('at hospital admission') is crucial and any discrepancies in documentation should be clarified before coding.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Neurology, Neurosurgery, Emergency Medicine, Critical Care Medicine
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Intensive Care Unit