(b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined.(a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated.The conditions and signs or symptoms included in categories R00- R94 consist of:.8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification.This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.toxic encephalopathy, anoxic encephalopathy) can be coded. acute or chronic delirium, dementia, coma) and the underlying cause (e.g. Given that most of the specified altered mental statuses vary with differing types of encephalopathy, I believe that if these three elements of CDI review are answered that both the manifestation (e.g. Linkage of the cause and effect of these two condition.
The nature of the encephalopathy: Options include hypertensive, metabolic, anoxic, toxic, hepatic, etc.The nature of the altered mental status: Options include dementia, delirium, psychosis, stupor, coma, etc.Given that R41.82 is a Chapter 18 symptom code, given that the ICD-10-CM Official Guidelines for Coding and Reporting state that “ Signs and symptoms that are associated routinely associated with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” and given that an altered mental status is integral to having an encephalopathy, I would only report G93.40.Īfter CDI Effort: CDI specialists need to obtain the specificity of the following: R41.82 altered mental status, unspecified.
ICD 10 FOR ALTERED MENTAL STATUS CODE
Q: Can we code altered mental status as a manifestation and encephalopathy together?Ī: In answering the question, we must consider what is documented before or after the CDI effort.īefore CDI Effort: If all that is documented is “altered mental status” and “encephalopathy,” I would assign the following two codes:
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