Physician Update

Glasgow Coma Scale Update

Prior to Oct. 1, 2016, the Glasgow Coma Scale was only coded and reported with traumatic brain injuries, CVAs (cerebrovascular accidents) and sequelae of CVAs. The GCS can now be reported when documented on any case in which there is monitoring of the central nervous system to describe impairment of consciousness from any cause.

Physicians must document the associated diagnosis that correlates to the reason the GCS is being addressed such as encephalopathy, stroke, overdose, etc. However, individual coma scale scores can be captured when documented by other clinicians involved in the patient's care (EMT, nursing) and not only by the physician. The total score is only reported when there is no documentation in the record indicating the individual scores.

Individual GCS scores have the potential to greatly impact the DRG and MCCs as well as severity of illness and risk of mortality. CMS uses certain GCS scores for risk adjustment in a variety of quality metrics including mortality, readmission reduction and Medicare spending per beneficiary.

Example of codes for best motor response:

Contact Emily Vollmeier