Glasgow coma scale score 9-12, EMR

This code indicates a moderate impairment of consciousness, as measured by the Glasgow Coma Scale (GCS), upon a patient's initial presentation to the emergency department. A GCS score between 9 and 12 suggests a significant neurological deficit, often due to head injury, stroke, or other acute cerebral insult.

Apply this code when documentation explicitly states a GCS score between 9 and 12 recorded at the time the patient first arrived at the emergency department. This is typically used in conjunction with a primary diagnosis explaining the cause of the altered mental status.

• Always sequence this code after the primary diagnosis indicating the underlying condition causing the altered mental status.
• Ensure the documentation specifies "at arrival" to the emergency department to differentiate from GCS scores taken at other times or locations.
• Do not use this code if the GCS score is outside the 9-12 range, or if the documentation does not specify the "at arrival" context.