2025 ICD-10-CM code R40.22
(Active) Effective Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Symptoms and signs involving cognition, perception, emotional state and behavior Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Coma scale, best verbal response.
Medical necessity for the use of R40.22 is established by the need to assess and document a patient’s level of consciousness for diagnostic and treatment purposes, commonly in cases of neurological impairment or trauma.
Clinicians use this code to document a patient's level of consciousness based on their best verbal response, as part of a neurological assessment.
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46)
In simple words: This code describes how well a person in a coma can respond verbally, which helps doctors understand how severe their condition is.
This code describes the level of consciousness of a patient based on their best verbal response using the Glasgow Coma Scale (GCS).The GCS assesses the best eye, verbal and motor responses.This code specifically refers to the verbal component.
Example 1: A patient involved in a motor vehicle accident is brought to the emergency room. They are assessed using the Glasgow Coma Scale, and their best verbal response is documented using code R40.22 along with R40.21 (eye opening response) and R40.23 (best motor response)., A patient with a history of seizures presents to the hospital with altered mental status.They open their eyes in response to pain (R40.21), and can follow commands by localizing painful stimuli. (R40.23) Their best verbal response consists of incomprehensible sounds. (R40.22), A patient in the intensive care unit following cardiac arrest is being monitored for neurological recovery.Their Glasgow Coma Scale score is recorded regularly, using this code to document the verbal response component, such as oriented conversation, inappropriate words or sounds.
Documentation should include the complete Glasgow Coma Scale assessment, specifying the best eye, verbal, and motor responses. Details of the events leading to the altered level of consciousness, such as trauma, medical conditions or substance use, should be documented.Any associated injuries or conditions should also be noted.
** R40.22 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 7th character should be used to specify the time at which the best verbal response was observed, using the valid values in ICD-10-CM guidelines.
- 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, Ambulance - Air or Water, Military Treatment Facility, etc.