2025 ICD-10-CM code R40.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - Somnolence, stupor and coma XVIII. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Coma: a state of prolonged unconsciousness.
Modifiers might be applied based on the circumstances of the encounter (e.g., place of service, type of service provided)and the underlying cause, consistent with CPT and HCPCS modifier guidelines.
Medical necessity for the care of a comatose patient stems from the life-threatening nature of the condition.Treatment is essential to maintain vital functions and prevent irreversible brain damage. Documentation must substantiate the need for continuous monitoring, supportive care, investigations into the underlying cause, and treatment based on those findings.
The clinical responsibility for a patient in a coma involves continuous monitoring of vital signs, managing airway and breathing, providing supportive care to maintain organ function, investigating underlying causes, and implementing treatment to address those causes. The treating physician's role is crucial in directing and coordinating this care.
- XVIII. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R40-R46: Symptoms and signs involving cognition, perception, emotional state and behaviour
In simple words: Coma is a deep sleep where a person is completely unconscious and doesn't respond to anything.It's a very serious medical emergency and needs immediate medical attention.
R40.2 Coma represents a state of prolonged unconsciousness, characterized by a lack of responsiveness to external stimuli and an absence of spontaneous movements.It's a serious condition requiring immediate medical attention.This code encompasses various types of coma, including those with specified coma scales (e.g., R40.21-R40.23) and unspecified coma (R40.20).It's crucial to document the specific details of the coma to ensure appropriate coding, especially coma scales (if applicable).Underlying causes should be investigated and documented as separate codes, as this code only addresses the state of coma itself. Excludes conditions with specific etiologies like diabetic, hepatic, hypoglycemic, neonatal, or uraemic comas, which require distinct ICD-10 codes.
Example 1: A 65-year-old male presents to the emergency department after a motor vehicle accident, exhibiting unresponsive behavior and absent reflexes.Diagnosis: Coma (R40.2) secondary to traumatic brain injury (S06.9). Further investigations (CT scan, MRI) revealed an intracranial hemorrhage, coded separately. , A 28-year-old female is found unconscious at home with empty pill bottles nearby.The physician diagnoses a coma (R40.2) secondary to drug overdose.The specific drug(s) involved need to be recorded in the appropriate section.Additional codes reflecting the poisoning might be necessary., A 72-year-old male is admitted to the hospital with progressive altered mental status. The patient's condition deteriorates, and a coma (R40.2) ensues.Underlying conditions, such as stroke or an intracranial infection, would be identified and coded separately.The Glasgow Coma Scale (GCS) should be recorded as R40.21, R40.22, or R40.23 with appropriate fifth digits if available, indicating the level of consciousness.
Complete history and physical examination; Glasgow Coma Scale (GCS) scores if applicable, including specific details (eyes open, motor response, verbal response); results of neurological examination; imaging studies (CT scan, MRI); laboratory tests (blood glucose, electrolytes, toxicology screen); documentation of any underlying medical conditions or precipitating events.
** The R40.2 code should only be used when the coma is the primary diagnosis and the etiology is not specified or fully understood.Underlying conditions and any interventions should be documented and coded appropriately.
- Payment Status: Active
- Modifier TC rule: Not applicable for ICD-10 codes. TC modifiers are used with CPT codes.
- Specialties:Neurology, Neurosurgery, Emergency Medicine, Critical Care Medicine, Internal Medicine
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Intensive Care Unit (ICU), Skilled Nursing Facility