2025 ICD-10-CM code R40.2354
(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) Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Coma scale: best motor response, localizes pain, 24 hours or more post-hospital admission.
The medical necessity for coding R40.2354 stems from the need to accurately document the patient's level of consciousness and neurological status during coma.This is critical for treatment planning, prognosis assessment, and monitoring of the patient's progress. The specific code reflects the level of impairment observed, aiding in precise communication between healthcare providers. Accurate coding is also needed for appropriate billing and reimbursement from insurance carriers. Accurate assessment of coma severity necessitates a validated scoring system such as the GCS, and appropriate documentation of the results are essential.
Neurological examination and assessment of level of consciousness.Documentation of the Glasgow Coma Scale (GCS) or equivalent scoring system is essential.
- 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 specific measurement of a patient's responsiveness (level of consciousness) during a coma.The doctor checks how the patient reacts to pain after being in the hospital for at least 24 hours.This particular code applies if the patient shows a response to pain by trying to move the painful area.
This ICD-10-CM code signifies a coma assessment where the patient's best motor response is localizing pain, as determined by the Glasgow Coma Scale (GCS) or similar neurological examination. This assessment is performed 24 hours or more after the patient's hospital admission.The code is specifically for situations where the motor response is documented as "localizes pain," distinguishing it from other motor responses on the GCS.The timing specification (24+ hours post-admission) is crucial for accurate coding.
Example 1: A patient admitted to the hospital after a motor vehicle accident is unresponsive. 24 hours post-admission, neurological examination reveals that the patient localizes pain, indicating the best motor response. R40.2354 is assigned., A patient presents with altered mental status due to an intracranial bleed.After 48 hours of hospitalization, the patient's GCS indicates that their best motor response is localizing pain. R40.2354 is used in this case., A patient with a severe traumatic brain injury is admitted to the ICU.After 72 hours of admission, the patient's neurological status shows a best motor response of localizing pain. This clinical finding is coded using R40.2354.
Detailed neurological examination notes including the Glasgow Coma Scale (GCS) or equivalent scoring system, specifying the best motor response as "localizes pain."The date and time of the assessment are crucial, confirming that the assessment happened 24 hours or more after admission.Physician documentation should clearly state the findings and support the use of this specific code.Supporting documentation might include other pertinent lab results or imaging reports.
** This code is used exclusively for coma assessments where the "localizes pain" response is observed 24 hours or more after admission.The code does not apply to the initial assessment at admission or assessments conducted within 24 hours of admission. The specific time point (24 hours post-admission) is a critical factor in selecting this code. Any discrepancies should be resolved through consultation with a medical coding specialist.
- Payment Status: Active
- Specialties:Neurology, Neurosurgery, Critical Care Medicine, Emergency Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Intensive Care Unit (ICU)