Coma scale, best motor response, flexion withdrawal, 24+hrs

This code indicates a patient's best motor response on the Glasgow Coma Scale (GCS) is flexion withdrawal, specifically when assessed 24 hours or more after hospital admission. Flexion withdrawal is a motor response to pain where the patient attempts to pull away from the stimulus. It signifies a moderate level of neurological impairment.

Apply this code when documentation clearly states a GCS motor score of 4 (flexion withdrawal) and specifies that this assessment occurred at least 24 hours post-admission. This is typically used for patients with traumatic brain injury, stroke, or other conditions causing altered mental status requiring prolonged monitoring.

• Ensure the documentation explicitly states "flexion withdrawal" as the best motor response and the timeframe of "24 hours or more after admission."
• Do not confuse with decorticate posturing (GCS motor score 3) or decerebrate posturing (GCS motor score 2).
• Always sequence this code after the primary diagnosis indicating the underlying condition causing the altered mental status.