Glasgow coma scale score 13-15, at hospital admission

This code indicates a patient's neurological status upon arrival at the hospital, specifically a Glasgow Coma Scale (GCS) score between 13 and 15. A GCS of 13-15 signifies a mild head injury or a patient who is generally alert and oriented, with minimal to no impairment of consciousness. It reflects the patient's best motor, verbal, and eye-opening responses.

Apply this code when documentation clearly states the patient's GCS score was 13, 14, or 15 at the time of hospital admission. This is typically used in conjunction with codes for the underlying injury or condition that prompted the admission. Supporting documentation includes physician notes, emergency department records, or nursing assessments explicitly detailing the GCS components and total score on admission.

• This code is for admission GCS only; do not use for subsequent GCS scores during the hospital stay.
• Always sequence this code after the primary diagnosis for the injury or condition.
• Do not use if the GCS score is not explicitly documented as 13-15 at admission; use unspecified or other GCS codes as appropriate.