2025 ICD-10-CM code R68.0
Hypothermia not associated with a low environmental temperature.
Medical necessity for R68.0 is established by documenting a clinically significant low body temperature in the absence of cold exposure and with appropriate efforts to identify and address underlying medical conditions contributing to the hypothermia. The documentation should demonstrate the need for medical intervention to manage the hypothermia and any associated health risks.
Clinicians should carefully document the patient's symptoms, relevant history, and examination findings to support the diagnosis of hypothermia not associated with low environmental temperature. It's essential to rule out other possible causes of hypothermia, such as exposure to cold, endocrine disorders, or drug side effects, before assigning this code.
- R: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- R00-R99: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classifiedR50-R69: General symptoms and signs
In simple words: This code represents a low body temperature that is not due to being in a cold environment.
Hypothermia, not associated with low environmental temperature. This code describes a state of abnormally low body temperature that isn't caused by exposure to cold surroundings.
Example 1: A 70-year-old patient presents to the emergency department with confusion and slurred speech. Their body temperature is measured at 34°C (93.2°F). The patient's history and examination reveal no recent exposure to cold environments. Further investigation reveals an underactive thyroid as the underlying cause., A 35-year-old patient with a history of drug abuse is brought to the hospital unconscious. Their body temperature is significantly low. No evidence of exposure to cold is found. Toxicological tests identify an overdose of a sedative medication as the cause of the hypothermia., A 55-year-old patient with sepsis develops hypothermia despite receiving appropriate treatment and being in a temperature-controlled environment. The hypothermia is considered a manifestation of the severe infection and organ dysfunction related to sepsis.
Documentation should include the patient's core body temperature, the time and method of temperature measurement, symptoms associated with hypothermia, a thorough history to identify potential underlying causes, and relevant physical examination findings. It's also necessary to document efforts to rule out other reasons for the low body temperature.
** Distinguishing R68.0 from other causes of hypothermia is essential for accurate coding and subsequent patient care and analysis. This code specifically addresses hypothermia not attributable to low environmental temperatures, thus prompting investigation for alternative underlying etiologies, such as metabolic disorders, sepsis, or drug effects.
- Specialties:Emergency medicine, Internal medicine, Critical care medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office