ICD-10 Coding for Change in Mental Status(R41.82, F05)
Complete ICD-10-CM coding and documentation guide for Change in Mental Status. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Change in Mental Status
R40-R46Primary Range
Symptoms and signs involving cognition, perception, emotional state and behavior
This range includes codes for symptoms like altered mental status, which are often used when a specific diagnosis is not yet determined.
Mental disorders due to known physiological conditions
This range includes codes for conditions like delirium and dementia, which can cause altered mental status.
Other disorders of brain
This range includes codes for encephalopathy, which is a common cause of altered mental status.
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 no specific cause for altered mental status is identified after evaluation. |
|
| F05 | Delirium due to known physiological condition | Use when delirium is due to a specific cause like infection or metabolic imbalance. |
|
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 change in mental status
Essential facts and insights about Change in Mental Status
Primary ICD-10-CM Codes for change in mental status
Decision Criteria
clinical Criteria
- No identifiable cause after 24-hour observation and negative workup.
coding Criteria
- Use only when no specific diagnosis can be made.
documentation Criteria
- Document detailed symptoms and negative findings.
Clinical Validation Requirements
- Normal CT head
- Normal metabolic panel
- Negative toxicology screen
Code-Specific Risks
- May lead to reimbursement denials if used as a primary code without supporting documentation.
Coding Notes
- R41.82 should not be used as a primary diagnosis if a more specific diagnosis is available.
F05 - Delirium due to known physiological condition
Use when delirium is due to a specific cause like infection or metabolic imbalance.
Applicable To
- Acute confusional state
- Delirium NOS
Excludes
- Dementia (F03.90)
- Alcohol withdrawal delirium (F10.231)
Clinical Validation Requirements
- Abnormal labs indicating infection or metabolic imbalance
- Acute onset and fluctuating course
Coding Notes
Always code the underlying cause of delirium first.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Unspecified dementia without behavioral disturbance
F03.90Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Change in 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 misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Use structured templates for documentation., Ensure all relevant clinical findings are recorded.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Ensure a thorough workup is documented and consider more specific codes if available.
Impact
Frequent use of R41.82 without supporting documentation.
Mitigation Strategy
Ensure thorough documentation and consider more 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 Change in Mental Status, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Change in Mental Status
Use these documentation templates to ensure complete and accurate documentation for Change in Mental Status. These templates include all required elements for proper coding and billing.
Emergency Department Evaluation
Specialty: Emergency MedicineRequired Elements
- Patient history
- Physical examination findings
- Diagnostic test results
- Clinical impression
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Change in Mental Status? Ask your questions below.