2025 ICD-10-CM code R41.81
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms, signs and abnormal clinical and laboratory findings - Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46) Chapter 19: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Age-related cognitive decline; a decline in cognitive abilities not present since birth or early development.
Medical necessity for the evaluation and management of age-related cognitive decline is established when there is a documented decline in cognitive function that impacts the patient's ability to perform activities of daily living or poses a risk to their safety.The extent of medical necessity depends on the severity of symptoms and the need for further investigations.
The clinical responsibility for diagnosing and managing age-related cognitive decline involves a thorough assessment of cognitive function, a comprehensive medical history, neurological examination, and often neuropsychological testing.Depending on the severity and underlying cause, management may include medication, therapy, lifestyle modifications, and supportive care.
- Chapter 19: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R41.81 falls under the broader category of R41 (Cognitive disorders), which is itself part of Chapter 19 (Symptoms, signs and abnormal clinical and laboratory findings).
In simple words: This code describes a gradual decline in thinking skills, such as memory and concentration, that happens as people age. It's used when doctors aren't yet sure what's causing the decline.
R41.81, Age-related cognitive decline, is an ICD-10-CM code that signifies a decrease in cognitive function that is not a developmental condition. This decline represents a deterioration from a previously higher level of cognitive ability.The condition is characterized by impairments in cognitive domains such as memory, attention, executive function, language, and visuospatial skills. It's crucial to note that this code is used when a more specific diagnosis cannot be established, even after thorough investigation. The symptoms may be indicative of various underlying conditions like Alzheimer's disease, vascular dementia, or other neurodegenerative disorders.
Example 1: An 80-year-old patient presents with progressive memory loss, difficulty with problem-solving, and decreased concentration over the past year.After a comprehensive evaluation, no specific diagnosis can be made, and R41.81 is assigned. , A 75-year-old patient presents with complaints of forgetfulness and mild difficulty with word-finding.A cognitive assessment reveals mild impairment but not meeting the criteria for dementia. R41.81 might be used in this situation while further investigations are carried out., A 68-year-old patient with a history of hypertension and hyperlipidemia is experiencing a subtle decline in cognitive function. Extensive testing does not reveal a specific cause.R41.81 could be assigned as a placeholder until a more definitive diagnosis is available.
Comprehensive documentation should include a detailed history of the patient's cognitive function, including onset, progression, and impact on daily life.Results of cognitive assessments (e.g., Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA)), neurological examination findings, and any relevant laboratory or imaging studies should be documented.
** R41.81 is a non-specific code and should only be used when a more specific diagnosis is not possible.Further investigation is usually necessary to determine the underlying cause of the cognitive decline.
- Payment Status: Active
- Specialties:Geriatric medicine, neurology, psychiatry
- Place of Service:Office, hospital inpatient, skilled nursing facility