2025 ICD-10-CM code R40
(Active) Effective Date: N/A Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified - Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46) 18. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Feed
Somnolence, stupor, and coma.A state of near-sleep, unresponsiveness, or deep unconsciousness.
Medical necessity is established by the clinical presentation of altered consciousness, which requires evaluation and management to determine the underlying cause and prevent further complications.
Clinicians responsible for assessing and managing altered levels of consciousness, including neurologists, emergency physicians, and critical care specialists.
- 18. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46)
In simple words: This code represents reduced alertness, responsiveness, and in severe cases, complete unconsciousness.
This code encompasses various levels of impaired consciousness, ranging from drowsiness (somnolence) to near-unconsciousness (stupor) and complete unconsciousness (coma).It is used when no more specific diagnosis can be made.
Example 1: A patient presents to the emergency room with decreased responsiveness and slurred speech after a suspected drug overdose.Initial diagnosis: R40., A patient with a history of diabetes is found unresponsive at home.While awaiting lab results to confirm diabetic coma, R40 is used., A patient post-head injury experiences fluctuating levels of consciousness, ranging from drowsiness to periods of unresponsiveness. R40 is applied until a more definitive diagnosis is made.
Detailed clinical documentation of the patient's level of consciousness, including response to stimuli, Glasgow Coma Scale score (if applicable), and any associated symptoms (e.g., confusion, disorientation).Documentation of underlying causes or contributing factors is also essential.
** Excludes1: neonatal coma (P91.5) somnolence, stupor and coma in diabetes (E08-E13) somnolence, stupor and coma in hepatic failure (K72.-) somnolence, stupor and coma in hypoglycemia (nondiabetic) (E15).
- Specialties:Neurology, Emergency Medicine, Critical Care, Internal Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Home, Nursing Facility, Skilled Nursing Facility