Slowness and poor responsiveness
ICD-10 R46.4 is a billable code used to indicate a diagnosis of slowness and poor responsiveness.
Slowness and poor responsiveness (ICD-10 code R46.4) refers to a clinical presentation characterized by a noticeable decrease in the speed of response to stimuli, both verbal and physical. This condition may manifest as lethargy, delayed reactions, or an overall lack of engagement with the environment. It can be indicative of various underlying medical issues, including neurological disorders, metabolic imbalances, or psychiatric conditions. Common causes include infections (such as meningitis), metabolic disturbances (like hypoglycemia), and neurological conditions (such as stroke or dementia). The assessment of slowness and poor responsiveness often involves a thorough clinical evaluation, including a detailed history, physical examination, and potentially neuroimaging or laboratory tests to identify the underlying cause. It is crucial to differentiate this symptom from other conditions that may present similarly, as the management and implications can vary significantly based on the underlying etiology.
Detailed patient history, physical examination findings, and any relevant lab results must be documented to support the diagnosis of slowness and poor responsiveness.
Patients presenting with fatigue, confusion, or altered mental status in a primary care setting.
Consideration of chronic conditions that may contribute to symptoms, such as diabetes or thyroid disorders.
Acute care documentation must include vital signs, neurological assessments, and any immediate interventions performed.
Patients presenting with altered mental status or lethargy following trauma or acute illness.
Rapid assessment and documentation are critical to rule out life-threatening conditions.
Used when a patient presents with slowness and poor responsiveness for evaluation.
Document the history, examination, and medical decision-making.
Internal medicine may require more detailed documentation of chronic conditions.
Use R46.4 when a patient presents with slowness and poor responsiveness that cannot be attributed to a more specific diagnosis. Ensure that the clinical documentation supports this coding.
