Glasgow coma scale score 13-15, EMR

This code indicates a patient's neurological status upon arrival at the emergency department, specifically reflecting a Glasgow Coma Scale (GCS) score between 13 and 15. This range signifies a mild brain injury or a patient who is generally alert and oriented, though potentially with some minor neurological deficits. It is a key indicator of the initial severity of a patient's altered mental status.

Use this code when documentation clearly states a GCS score of 13, 14, or 15 recorded upon the patient's arrival at the emergency department. This is commonly seen in cases of trauma, suspected concussion, or other conditions affecting neurological function where an initial assessment of consciousness is performed. The GCS score must be explicitly documented.

• Always ensure the documentation specifies "at arrival to emergency department" for accurate code assignment.
• Do not use this code for GCS scores documented at different time points (e.g., at discharge, during hospitalization) or in other settings.
• This code should be sequenced after the primary diagnosis indicating the reason for the patient's altered mental status or injury.