Coma scale, best motor response, extension, unspecified time

This code indicates a specific finding on the Glasgow Coma Scale (GCS), reflecting a patient's motor response to stimuli. Specifically, it denotes an extension response, which is an abnormal posturing where the limbs extend, often indicating significant brain injury. This particular code signifies that the timing of this observation was not documented.

Use this code when documentation clearly states a GCS motor score of 2 (extension) but does not specify whether this was on admission, at discharge, or at another defined time point. This is typically seen in emergency department notes, critical care progress notes, or neurological assessments where a GCS is performed.

• Ensure the documentation explicitly states "extension" as the best motor response.
• Only use this code when the timing of the GCS assessment is not specified. If timing is documented (e.g., "on admission"), a more specific code from the R40.23- series should be used.
• This code should be sequenced as a secondary diagnosis, following the primary diagnosis for the underlying condition causing the altered mental status.