Other coma, without Glasgow, or w/part score, unsp time

This code signifies a state of profound unconsciousness where the patient is unresponsive to external stimuli, and the Glasgow Coma Scale (GCS) score is either not fully documented or only partially recorded. It represents a severe alteration in neurological function without further specification regarding the cause or the exact GCS score.

This code is appropriate when a patient presents with a coma, and the medical record explicitly states that a complete GCS score was not obtained or only a component of the GCS was documented (e.g., only eye opening or verbal response). It is used when the specific etiology of the coma is unknown or not yet determined.

• Do not use this code if a complete GCS score is documented; instead, use a more specific R40.2- code that includes the GCS score.
• Always sequence a code for the underlying cause of the coma (e.g., stroke, traumatic brain injury, metabolic encephalopathy) before this code, if known.
• Avoid using this code if the documentation clearly indicates a specific type of coma (e.g., anoxic brain damage, diabetic coma) for which a more precise code exists.