Coma scale, best motor response, flexion withdrawal, EMR

This code indicates a specific component of the Glasgow Coma Scale (GCS) assessment, reflecting a patient's best motor response as "flexion withdrawal." This response, characterized by withdrawal of a limb from a painful stimulus, signifies a moderate level of neurological impairment. The assessment is specifically documented upon the patient's arrival at the emergency department.

This code is used when a GCS assessment is performed in the emergency department, and the patient's best motor response to a painful stimulus is recorded as flexion withdrawal. Documentation must clearly state the GCS motor component as "flexion withdrawal" and specify that this finding was observed upon arrival to the ED. It is typically applied in cases of head injury, stroke, or other conditions affecting neurological function.

• Ensure the documentation explicitly states "flexion withdrawal" for the motor component and "at arrival to emergency department."
• Do not use this code if the motor response is different (e.g., obeys commands, localizes pain, abnormal flexion, extension, or no response).
• This code should be sequenced with other GCS component codes (eye opening, verbal response) and the underlying condition causing the altered mental status.