Glasgow coma scale score 9-12, at hospital admission

This code indicates a moderate impairment of consciousness, as measured by the Glasgow Coma Scale (GCS), upon a patient's admission to a hospital setting. A GCS score between 9 and 12 suggests a significant neurological deficit, often due to head injury, stroke, or other acute brain insult, affecting eye-opening, verbal response, and motor response.

Apply this code when documentation clearly states a GCS score of 9, 10, 11, or 12 recorded at the time of the patient's initial hospital admission. This is typically used for patients presenting with altered mental status following trauma, medical emergencies, or neurological events. The GCS score must be explicitly documented by a physician or other qualified healthcare professional.

• Always ensure the documented GCS score falls precisely within the 9-12 range for admission.
• Do not use this code for GCS scores recorded after the initial hospital admission; specific codes exist for subsequent encounters.
• Sequence this code after the primary diagnosis indicating the underlying cause of the altered mental status (e.g., traumatic brain injury, stroke).