Q&A: Capturing loss of consciousness status

Q: I primarily work in the neurosurgery review lane within CDI and am seeking further guidance on best practices for capturing loss of consciousness (LOC) status in cases of traumatic subdural or subarachnoid hemorrhage. Current definitions of LOC appear broad and can be challenging to gain physician consensus on, particularly when it comes to documentation. While some Coding Clinics provide direction regarding timeframe, obtaining clear physician statements on LOC status remains difficult, despite its impact on DRG assignment.

For example: A patient presents after a fall with a traumatic subdural hemorrhage. On arrival, the patient’s CT confirms the diagnosis, and their Glasgow Coma Score (GCS) is 11. The patient is combative, altered, and unaware of their surroundings. In this scenario, should this presentation be considered a loss of consciousness? Or does LOC require documentation of a syncopal-type event to be coded as positive?

A: LOC in the setting of traumatic intracranial hemorrhage is defined clinically and coded based on whether the patient truly had a period of being non-arousable and without awareness, not simply confused, combative, or altered. ICD-10-CM relies on clear physician documentation to determine whether LOC occurred and, if so, the approximate duration. Abnormal mentation alone does not equal LOC.

LOC duration cannot be inferred from GCS scores or from the presence of confusion, agitation, posttraumatic amnesia, or intoxication. LOC must be specifically documented or clearly supported by a physician statement. The timeframe is meant to reflect the period in which the patient was nonresponsive or unconscious, not the duration of altered mental status after waking.

Using your example:

A patient presents after a fall with a traumatic subdural hemorrhage. CT confirms hemorrhage and the GCS is 11. They are combative, altered, and disoriented. This pattern is frequently due to acute intracranial injury but represents posttraumatic confusion, not LOC, unless the physician documents that the patient had a definite period of unconsciousness at the scene, en route, or upon arrival at the emergency department.

In relation to coding, diagnosed syncope is not required. LOC can follow blunt head trauma and may be witnessed by bystanders, emergency medical services (EMS), or clinical staff. LOC cannot be assumed from disorientation, agitation, or a depressed GCS alone. Coding Clinic has repeatedly clarified that LOC duration must be explicitly documented.

If the provider states “brief LOC,” “uncertain LOC,” “LOC duration unknown,” or “patient found unconscious,” these statements support assignment of an LOC code. If the provider only documents confusion or altered mental status with no statement about unconsciousness, then the default is “no loss of consciousness.”

CDI professionals should query when documentation shows altered mentation but no clear description of LOC. Use language such as: “Can you clarify whether there was any loss of consciousness associated with the traumatic intracranial hemorrhage and, if so, the approximate duration?” or “GCS 11 on arrival with altered mentation, combative behavior, and disorientation. EMS did not document whether the patient was awake at the scene. Can you please clarify whether the patient experienced a loss of consciousness and the timeframe if known?”

When it comes to provider/nursing/staff education, we want to make it clear that documentation should reflect whether it was present and timeframe if known. For example, “Loss of consciousness timeframe was _______________.” Remind teams that “LOC duration unknown” is acceptable. For unwitnessed falls or elderly patients found on the floor, physicians may accurately document “loss of consciousness duration unknown,” which is a valid assignable code and often clinically appropriate.

Other relevant conditions to consider are coma, posttraumatic amnesia, posttraumatic confusion, or ongoing encephalopathy due to the hemorrhage.

Here are some references as well:

• “Traumatic Brain Injury Coding in ICD-10-CM,” by Theresa Rihanek, MHA, RHIA, CCS (Journal of AHIMA | November 18, 2024)
• “ICD-10-CM Coding Guidance for Traumatic Brain Injury” (Traumatic Brain Injury Center of Excellence | December 2019)
• American Hospital Association Coding Clinic for ICD-10-CM/PCS, fourth quarter 2022: “Intracranial Injury with Unknown Loss of Consciousness.”

• “Note from the Instructor: Coding Clinic, second quarter 2021, high and lowlights” (CDI Strategies, vol. 15, issue 27 | July 8, 2021)
• “Physician advisors: Becoming a trusted resource” (CDI Journal, vol. 14, issue 4 | July 1, 2020)

Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education director at ACDIS/HCPro, answered this question. Contact her at deanne.wilk@hcpro.com.