2025 ICD-10-CM code R40.2351
(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 XVIII: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Coma scale; best motor response, localizes pain, in the field (EMT or ambulance).
Modifiers are not applicable to ICD-10-CM codes.
The medical necessity for coding R40.2351 is established by the documentation of the patient's comatose state and the assessment of the best motor response to pain as observed by the EMT or in the ambulance.This reflects the clinical scenario at the time of the initial encounter.Medical necessity is further supported by the need for immediate care and further investigations at a hospital.
The clinical responsibility for coding R40.2351 rests with the physician or qualified healthcare professional who assessed the patient and documented the coma and the best motor response.The EMT or ambulance personnel's documentation is crucial for accurate coding.
- Chapter 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 behavior
In simple words: This code describes a situation where a person is in a coma, and medical personnel in an ambulance or emergency medical service determined the person can only move in response to pain.Doctors use this code when they can't pinpoint the reason for the coma immediately.
This ICD-10-CM code, R40.2351, signifies a coma assessment where the patient's best motor response is localization to pain, specifically documented in a pre-hospital setting by an Emergency Medical Technician (EMT) or within an ambulance.This code is used when a more definitive diagnosis cannot be established at the time of the initial encounter. The assessment is limited to the motor response and does not encompass other aspects of the Glasgow Coma Scale (GCS).
Example 1: A patient is found unconscious at the scene of a motor vehicle accident.An EMT assesses the patient using the Glasgow Coma Scale and documents a best motor response of localizing to pain.R40.2351 is used at the initial encounter until further investigation and diagnosis can be made at the hospital., A patient is experiencing a seizure and loses consciousness.Post-seizure, an EMT evaluates the patient and documents localization to pain as the best motor response.R40.2351 is coded in the pre-hospital setting pending a more definitive diagnosis in the hospital., A patient is unresponsive during transport to the hospital following a fall.The EMT's documentation indicates the patient only responds to painful stimuli. R40.2351 is used at the initial encounter for the coma, which would be further investigated and definitively diagnosed in the hospital.
Detailed documentation of the patient's presentation, including level of consciousness, response to stimuli (including pain), and any other relevant clinical findings from the EMT or pre-hospital medical personnel.The documentation must support the use of R40.2351.Hospital documentation should also be reviewed to confirm any changes in diagnosis.
** R40.2351 should only be used when the best motor response documented is the localization to pain during a coma.This is often an initial assessment before a more definitive diagnosis is made. The code should be used cautiously, ensuring that it accurately reflects the clinical presentation at the time of the initial encounter.It is crucial to review complete medical records for more accurate coding.
- Revenue Code: Revenue codes will depend on the specific services rendered and the payer's guidelines.Consult the payer's instructions and the facility's revenue code assignment guidelines for the appropriate codes.
- RVU: RVUs are not applicable to ICD-10-CM codes.RVUs are used for CPT and HCPCS codes to determine reimbursement.
- Global Days: Not applicable to ICD-10-CM codes.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10-CM codes.
- Fee Schedule: Not applicable to ICD-10-CM codes.
- Specialties:Emergency Medicine, Neurology, Neurosurgery
- Place of Service:Ambulance - Land, Ambulance - Air or Water