ICD-10 Coding for Altered Mental Status(R41.82, F05)
Complete ICD-10-CM coding and documentation guide for Altered Mental Status. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Altered Mental Status
R40-R46Primary Range
Symptoms and signs involving cognition, perception, emotional state and behavior
This range includes codes for various cognitive and mental status alterations, including R41.82 for unspecified altered mental status.
Delirium due to known physiological condition
Used when altered mental status is due to a known medical condition, such as delirium.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R41.82 | Altered mental status, unspecified | Use when the cause of altered mental status is not identified after a thorough evaluation. |
|
| F05 | Delirium due to known physiological condition | Use when delirium is confirmed to be due to a physiological condition. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for altered mental status
Essential facts and insights about Altered Mental Status
Primary ICD-10-CM Codes for altered mental status
Decision Criteria
clinical Criteria
- No identifiable cause after evaluation
documentation Criteria
- Detailed description of symptoms and negative findings
Clinical Validation Requirements
- Confusion and disorientation without identifiable cause
- Negative lab and imaging results
Code-Specific Risks
- Overuse of unspecified codes can lead to audit risks.
- May not capture the complexity of the patient's condition.
Coding Notes
- Ensure thorough documentation to justify the use of an unspecified code.
F05 - Delirium due to known physiological condition
Use when delirium is confirmed to be due to a physiological condition.
Applicable To
- Acute confusional state
Excludes
- Dementia (F03.90)
- Unspecified altered mental status (R41.82)
Clinical Validation Requirements
- Positive CAM-ICU
- Elevated WBC or CRP
Coding Notes
Ensure the underlying condition is documented and coded.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Altered Mental Status to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R41.82.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Thoroughly evaluate and document potential causes, Use specific codes when the cause is identified
Impact
Reimbursement: Incorrect coding can lead to lower reimbursement., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of clinical data.
Mitigation Strategy
Code the underlying condition first, such as F05 for delirium.
Impact
High use of unspecified codes can trigger audits.
Mitigation Strategy
Ensure thorough documentation and use specific codes when possible.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Altered Mental Status, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Altered Mental Status
Use these documentation templates to ensure complete and accurate documentation for Altered Mental Status. These templates include all required elements for proper coding and billing.
Emergency Department presentation with AMS
Specialty: Emergency MedicineRequired Elements
- Chief complaint
- History of present illness
- Physical examination findings
- Lab and imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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