Glasgow coma scale score 13-15, unspecified time

This code indicates a patient's neurological status as measured by the Glasgow Coma Scale (GCS), specifically a score between 13 and 15, which generally signifies a mild brain injury or a state of alertness. It reflects the patient's best motor, verbal, and eye-opening responses at an unspecified time during their care.

Use this code when documentation indicates a GCS score of 13, 14, or 15, and the specific timing of this assessment (e.g., "upon admission," "at discharge") is not recorded. This is typically seen in cases of head trauma, stroke, or other conditions affecting consciousness where a mild impairment or full consciousness is noted.

• Always seek documentation for a more specific GCS score and the timing of the assessment if available.
• Avoid using this code if a more precise GCS score (e.g., R40.21, R40.22, R40.23) or a specific timing (e.g., R40.2411, R40.2412, R40.2413) is documented.
• This code is often a secondary diagnosis, accompanying the primary diagnosis for the underlying condition causing the altered mental status.