Coma scale, best motor response, extension, EMR

This code indicates a specific finding on the Glasgow Coma Scale (GCS), reflecting a patient's best motor response as "extension" upon their initial presentation to the emergency department. Extension, also known as decerebrate posturing, is an abnormal motor response characterized by adduction and internal rotation of the shoulder, extension of the elbow, pronation of the forearm, and flexion of the wrist and fingers. It signifies significant brainstem dysfunction.

Apply this code when documentation clearly states the patient's best motor response on the GCS was extension, specifically recorded at the time of arrival to the ED. This is typically seen in patients with severe traumatic brain injury, stroke, or other conditions causing profound neurological impairment. The GCS score component must be explicitly documented by the ED physician or other qualified healthcare professional.

• Ensure the documentation specifies "at arrival to emergency department" for accurate code assignment.
• Do not use this code for motor responses observed after initial ED arrival or in other care settings.
• This code should be sequenced after the primary diagnosis indicating the underlying cause of the altered mental status.