Coma scale, best motor, flexion withdrawal, in the field

This code indicates a patient's best motor response on the Glasgow Coma Scale (GCS) as flexion withdrawal, specifically assessed by emergency medical services (EMS) personnel in a pre-hospital setting. Flexion withdrawal signifies a purposeful attempt to move away from a painful stimulus, but without localizing the pain. It reflects a moderate level of neurological impairment.

Use this code when EMS documentation clearly states a GCS motor score of 4, characterized by flexion withdrawal to pain, and the assessment was performed in the field (e.g., at the scene of an accident, in the patient's home before transport). This code is typically used in conjunction with codes for the underlying condition causing the altered mental status.

• Always verify that the GCS assessment was performed by EMS in the pre-hospital environment.
• Ensure the documentation explicitly states "flexion withdrawal" or a GCS motor score of 4.
• This code should be sequenced after the primary diagnosis explaining the patient's altered mental status (e.g., traumatic brain injury, stroke, overdose).