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2025 ICD-10-CM code R40.24

Glasgow Coma Scale (GCS) total score.

Code first the underlying cause of the coma (e.g., intracranial hemorrhage, traumatic brain injury) if known.Use this code (R40.24) only when only the total GCS score is available.

The medical necessity for using the Glasgow Coma Scale is determined by the clinical situation.It is essential for evaluating and monitoring patients with altered levels of consciousness due to various neurological conditions or injuries.The frequency of assessment may vary depending on the patient's condition.

Neurological assessment and management of altered consciousness. This may involve a range of professionals from emergency medicine physicians to neurosurgeons, depending on the patient's condition and need for interventions.

IMPORTANT:No alternate codes are specifically mentioned.However, depending on the clinical context, other codes from Chapter 19 (Injury, poisoning and certain other consequences of external causes) might be applicable if the coma is due to an external cause (e.g., head injury).

In simple words: This code is used when a doctor measures a patient's level of consciousness using a special test called the Glasgow Coma Scale. The test gives a total score that shows how alert the patient is, ranging from a low score (deeply unconscious) to a high score (fully awake).

This code represents the total score obtained from the Glasgow Coma Scale (GCS), a neurological assessment tool used to evaluate a patient's level of consciousness.The GCS assesses three aspects: eye opening, verbal response, and motor response, with each assigned a numerical score.The total score ranges from 3 (indicating deep coma) to 15 (indicating normal consciousness). This code is used when only the total GCS score is documented.

Example 1: A patient presents to the emergency department following a motor vehicle accident with decreased level of consciousness. The physician performs a neurological assessment including the Glasgow Coma Scale, resulting in a total score of 8.This code (R40.24) is used to document the GCS total score., A patient is admitted to the hospital after a stroke. Their level of consciousness is assessed using the Glasgow Coma Scale, resulting in a score of 12.R40.24 is used to document this., A patient in an intensive care unit after neurosurgery has their level of consciousness monitored using the Glasgow Coma Scale. The total score recorded by the nurse over a 24 hour period varies but a summary score, for instance 14 is documented using R40.24.

Complete documentation of the Glasgow Coma Scale assessment should include the individual scores for eye opening, verbal response, and motor response, in addition to the total score.The date and time of the assessment must be clearly recorded.Relevant clinical information such as the reason for the assessment (e.g., trauma, stroke, post-operative status) should also be documented.

** The Glasgow Coma Scale is a widely used tool, but interpretation and application must consider the clinical situation, patient age, and pre-existing conditions.

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