Guest Post: New ICD-10-CM/PCS codes up the ante in coding compliance, part 2: Pediatric Glasgow coma scales

by James S. Kennedy, MD, CCS, CDIP

Editor’s note: With the fiscal year 2018 ICD-10-CM/PCS codes released, Kennedy unpacked some of the compliance pitfalls and opportunities awaiting CDI and coding professionals when these new codes are implemented on October 1. Some of these issues may be addressed in the 2018 ICD-10-CM Official Guidelines for Coding and Reporting or the American Hospital Association’s Coding Clinic, Fourth Quarter, 2017, so be sure to compare Kennedy’s opinions with these documents. This article is part two in a three-part series. Click here to read part one. Return to the blog next week to read part three!

Pediatric Glasgow coma scales

In what should have been a welcome change, the National Center for Health Statistics amended the ICD-10-CM Alphabetic Index to allow for reporting of the clinical descriptors of the pediatric Glasgow coma scale. Notice that in the best motor response section, “flexion to pain” gets three points in the clinical scale whereas “withdrawal from pain” gets four points. Now notice how ICD-10-CM manages these conditions in 2018:

• 233-, Coma scale, best motor response, abnormal (not a MCC)
  
  • Abnormal flexure posturing to pain or noxious stimuli (0-5 years of age)
  • Flexion/decorticate posturing (< 2 years of age)
• 234-, Coma scale, best motor response, flexion withdrawal (a MCC)
  
  • Withdraws from pain or noxious stimuli (0-5 years of age)

Please note that the sixth digit of R40.233- is “3” which should correlate with “flexion withdrawal” in the clinical scale; however, the ICD-10-CM code for flexion response or withdrawal is in R40.234-. On the other hand, the pediatric descriptors for flexion response is under R40.233- (abnormal response), not R40.234-. (flexion withdrawal).

Remember also that Coding Clinic, Second Quarter, 2015, pp 17-18, allows ICD-10-CM coding based on the number (e.g., 1, 2, 3, 4) alone, not the clinical description. Therefore, if a provider documents only a score of three in a patient’s coma scale, indicating a flexion withdrawal or posturing as a best motor response, should R40.233- be reported (not an MCC) or R40.234- (an MCC) be reported? Would my answer be different in pediatrics or adults?

I urge you to work with your providers to explicitly document the clinical descriptions of the coma scales, not just the numbers, so that the proper code can be reported. Consider also establishing coding policy whereby the title of the R40.233- and R40.234-, not their subheading or how they are listed in the Index. For example, flexion withdrawals as a best response should only code to R40.234- and abnormal responses as a best response should only code to R40.233-, no matter what the age. This way, we don’t get a MCC that we don’t deserve if the best response is only an abnormal response, not a flexion response.

I also urge you to discuss this with the National Centers for Health Statistics and to send scenarios to the Coding Clinic editorial board.

Editor’s note: This article originally appeared in BCCS. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.