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v1.0.0
ICD-10 Guide
ICD-10 CodesR44.1

R44.1

Visual hallucinations

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R44.1 is a billable code used to indicate a diagnosis of visual hallucinations.

Key Diagnostic Point:

Visual hallucinations are perceptions of visual stimuli that are not present in the external environment. These can manifest as simple flashes of light, complex images, or entire scenes. Patients may report seeing people, animals, or objects that do not exist. Visual hallucinations can occur in various contexts, including psychiatric disorders, neurological conditions, substance use, and sensory deprivation. Common psychiatric causes include schizophrenia and severe mood disorders, while neurological causes may include dementia, Parkinson's disease, and migraines. The presence of visual hallucinations can significantly impact a patient's quality of life and may indicate underlying medical or psychological issues that require thorough evaluation. Clinicians should assess the patient's history, medication use, and any recent changes in health status to determine the etiology of the hallucinations. A comprehensive diagnostic approach may involve neurological examinations, psychiatric evaluations, and imaging studies to rule out structural brain abnormalities.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes (psychiatric, neurological, substance-related)
  • Need for comprehensive patient history and evaluation
  • Differentiation from other types of hallucinations
  • Potential overlap with other ICD codes

Audit Risk Factors

  • Inadequate documentation of the patient's history and symptoms
  • Failure to specify the underlying cause of hallucinations
  • Misuse of related codes leading to upcoding or downcoding
  • Lack of clarity in distinguishing between hallucinations and illusions

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including onset, duration, and context of hallucinations, along with any relevant medical history.

Common Clinical Scenarios

Patients presenting with visual hallucinations due to metabolic disturbances, infections, or medication side effects.

Billing Considerations

Consideration of comorbid conditions and the impact of medications on visual perception.

Emergency Medicine

Documentation Requirements

Acute assessment of visual hallucinations, including vital signs, mental status examination, and any immediate interventions.

Common Clinical Scenarios

Patients presenting with acute visual hallucinations due to substance intoxication or withdrawal.

Billing Considerations

Rapid assessment and stabilization of the patient, with clear documentation of the acute presentation.

Coding Guidelines

Inclusion Criteria

Use R44.1 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code R44
  • 1 is used only when visual hallucinations are documented and not attributable to other specified conditions
  • Ensure that the underlying cause, if known, is also coded appropriately

Exclusion Criteria

Do NOT use R44.1 When
No specific exclusions found.

Related CPT Codes

99214CPT Code

Established patient office visit, level 4

Clinical Scenario

Used when evaluating a patient with visual hallucinations in an outpatient setting.

Documentation Requirements

Document the patient's history, examination findings, and any diagnostic tests performed.

Specialty Considerations

Ensure that the visit is comprehensive and addresses the complexity of the patient's symptoms.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of visual hallucinations, improving the ability to capture the complexity of these symptoms and their underlying causes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of visual hallucinations, improving the ability to capture the complexity of these symptoms and their underlying causes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of visual hallucinations, improving the ability to capture the complexity of these symptoms and their underlying causes.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What should I document to support the use of R44.1?

Document the patient's description of the hallucinations, their duration, any associated symptoms, and any relevant medical history or medications that may contribute to the condition.