Definition: A prolonged state of unconsciousness from which the patient cannot be aroused. When documenting coma, include the duration of time in coma (greater or less than one hour).

This is especially important in patients with a principal diagnosis of:

  • subdural hematoma
  • closed head injury
  • skull fracture
  • subdural, extradural or subarachnoid hemorrhage
  • traumatic brain injury

ICD-10 will utilize the Glasgow Coma Scale. Total score documented on presentation may be used, however, the individual scores are preferred.

The documentation of coma supports higher severity of illness and increased length of stay as well as medical necessity.

Coma is not integral to the death process, and can be an additional diagnosis when a patient expires.

Download the complete tip, Coma.