Coma scale, eyes open, to sound, unspecified time

This code indicates a specific level of neurological responsiveness, where a patient opens their eyes in response to auditory stimuli. It signifies a moderate impairment in consciousness, as the patient is not spontaneously opening their eyes but can be aroused by sound. This assessment is a component of the Glasgow Coma Scale (GCS).

Use this code when documentation explicitly states a GCS score component for eye opening as "to sound" without a specified time frame for the assessment. This is commonly seen in emergency department evaluations, critical care settings, or neurological assessments following injury or illness. The physician's notes must clearly indicate this specific GCS finding.

• Ensure the documentation specifies "to sound" for eye opening, not "spontaneously" or "to pain."
• Do not use this code if a specific time frame for the GCS assessment is documented; instead, use the appropriate R40.21- code with the specified time.
• This code is typically used as a secondary diagnosis, accompanying a primary diagnosis describing the underlying condition causing the altered mental status.