2025 ICD-10-CM code R41.82
(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 Chapter 17: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified Feed
Altered mental status, unspecified; a change in mental state with no specific diagnosis.
Medical necessity for coding R41.82 is established when a patient exhibits a documented altered mental status, and despite a thorough evaluation, the underlying cause remains unknown or cannot be definitively identified.The use of the code implies that the condition warrants medical attention and further investigation to determine the etiology and implement appropriate treatment.
The clinical responsibility for coding R41.82 rests with the physician or qualified healthcare professional who has conducted a thorough assessment of the patient's mental status and determined that it is altered, but the cause is uncertain.This necessitates the documentation of the findings, evaluation, and the decision-making process leading to the use of this non-specific code.It is the responsibility of the clinician to ensure that all efforts have been made to determine a more specific diagnosis. This code should be used as a last resort when no other diagnosis fits.
- Chapter 17: Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified
- R41.82 falls under the broader category of R41 (Altered mental status) within Chapter 17 of the ICD-10-CM classification.
In simple words: This code means a doctor noticed a change in someone's mental state, but they don't know exactly what's causing it.It could be anything from confusion to being unconscious.
R41.82, Altered mental status, unspecified, is an ICD-10-CM code used to classify instances of a noticeable change in a patient's cognitive function, awareness, perception, and responsiveness to stimuli, when a more specific diagnosis cannot be established. This code signifies that the clinician has assessed the patient's mental status and determined that it is altered, but the underlying cause remains unknown or cannot be definitively specified.The altered mental state may range from mild confusion and disorientation to more severe conditions like stupor or coma. This code should only be used when a more specific diagnosis is not possible after thorough investigation.The use of this code necessitates appropriate documentation detailing the observed changes in mental status, the relevant examination findings, and the steps taken to determine the underlying cause.
Example 1: A patient presents to the emergency room with sudden onset confusion, disorientation, and slurred speech.After a complete work-up, including laboratory tests and imaging, no specific cause for the altered mental status can be determined.R41.82 is used., A nursing home resident exhibits a gradual decline in cognitive function, including memory loss and difficulty with daily tasks. A comprehensive assessment reveals no clear etiology, resulting in the use of R41.82., A patient is admitted to the hospital after a motor vehicle accident. Initial examination reveals altered mental status.Despite extensive testing, the cause remains unclear. R41.82 is utilized until further investigations clarify the etiology.
** This code is for use when a definite diagnosis cannot be made, even after all available information has been considered. It is a placeholder until a more specific diagnosis can be established.
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