R40.21 Coma scale, eyes open

The ICD-10-CM code for Coma scale, eyes open is R40.21 (FY2026). It is a non-billable category code — select a more specific code below for claims.

Classification

Chapter

18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Section

R40-R46: Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46)

Category R40

31 codes (25 billable)

FY2026 Status

Stable since FY2024

Official Coding Guidelines

Coma scale (R40.21-–R40.24-) use, sequencing, scoring, 7th character

1) Coma Scale The coma scale codes (R40.21- to R40.24-) can be used in conjunction with traumatic brain injury codes. These codes cannot be used with code R40.2A, Nontraumatic coma due to underlying condition. They are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale codes should be sequenced after the diagnosis code(s). These codes, one from each subcategory, are needed to complete the scale. The 7th character indicates when the scale was recorded. The 7th character should match for all three codes. At a minimum, report the initial score documented on presentation at your facility. This may be a score from the emergency medicine technician (EMT) or in the emergency department. If desired, a facility may choose to capture multiple coma scale scores. Assign code R40.24-, Glasgow coma scale, total score, when only the total score is documented in the medical record and not the individual score(s). If multiple coma scores are captured within the first 24 hours after hospital admission, assign only the code for the score at the time of admission. ICD-10-CM does not classify coma scores that are reported after admission but less than 24 hours later. See Section I.B.14. for coma scale documentation by clinicians other than patient's provider

Repeated falls vs history of falling

d. Repeated falls Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated. Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.

Source: CMS — ICD-10-CM Official Guidelines for Coding and Reporting, FY2026

References

• CMS — ICD-10-CM Official Code Set and Guidelines, FY2026
• CDC/NCHS — ICD-10-CM Files and Browser Tool