CDI ICD-10-CM Documentation Tips:
Coma
• ICD-10-CM will expand “coma”
to include coding for
somnolence, stupor, and coma
– Somnolence (R40.0) =
drowsiness
– Stupor (R40.1) = catatonic
stupor or semi-coma
– Coma (R40.2-) =
unconsciousness
• Any associated skull
fracture or intracranial
injury would be coded first
• 7th character required
• Glasgow (coma scale) score
available
• Glasgow (coma scale) score
available
– Typically reported as a total
score 0-15
• Higher score = higher
functioning
– ICD-10-CM coding will need
the score from each of the
assessment areas
• Eye opening
• Verbal response
• Motor response
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