Assign the correct ICD-10-CM diagnosis code(s). Enter cod…
Assign the correct ICD-10-CM diagnosis code(s). Enter codes using CAPITAL LETTERS If entering multiple codes, separate with a comma and a space (ex. R79.8, R05.9) ED Note Chief complaint: “Unresponsive after fall from ladder.” HPI: 47-year-old male fell approximately 12 feet, striking head on concrete. Transported by EMS. Exam in ED: GCS on arrival: Eye = 2 (to pain), Verbal = 2 (incomprehensible), Motor = 4 (withdraws from pain). Pupils unequal, left dilated. Imaging: CT head shows acute subdural hematoma, left hemisphere. Assessment: Acute traumatic subdural hematoma, left. Coma documented with initial GCS score: E2, V2, M4. Plan: Admit to ICU, neurosurgery consult, ICP monitoring. NOTE: Do not assign the injury code – Only assign Coma Scale Code(s) ICD-10-CM Code Assignment: Cite the coma scale guideline (ex. I.B.16):