Assign code R4 24 Glasgow coma scale total score when only the total score is

Assign code r4 24 glasgow coma scale total score when

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Assign code R4 0 .24, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s). f. Functional quadriplegia Functional quadriplegia (code R53.2) is the lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, and code R53.2 should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record. g. SIRS due to non-infectious process The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, or code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction. If an associated acute organ dysfunction is documented, the appropriate code(s) for the specific type of organ dysfunction(s) should be assigned in addition to code R65.11. If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried. Chest pain of unknown origin R07.9 Chest pain, unspecified Explanation: Codes that describe symptoms such as chest pain are acceptable for reporting purposes when the provider has not established (confirmed) a related definitive diagnosis. Pneumonia with hemoptysis J18.9 Pneumonia, unspecified organism R04.2 Hemoptysis Explanation: Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis. Abdominal pain due to acute appendicitis K35.80 Unspecified acute appendicitis Explanation: Codes for signs or symptoms routinely associated with a disease process should not be assigned unless the classification instructs otherwise. Acute gastritis with hemorrhage K29.01 Acute gastritis with bleeding Explanation: When a combination code identifies both the definitive diagnosis and the symptom, an additional code should not be assigned for the symptom. 23-year-old man found down after unknown injury with skull fracture and with concussion and loss of consciousness of unknown duration. EMS evaluated the patient in the field and reported the individual Glasgow coma scores: Eye opening response—3: eyes open to speech Verbal response—4: confused but coherent speech Motor response—6: obeys commands fully S02.0XXA Fracture of vault of skull, initial encounter for closed fracture S06.0X9A Concussion with loss of consciousness of unspecified duration, initial encounter R40.2131 Coma scale, eyes open, to sound, in the field [EMT or ambulance] R40.2241
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