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ICD-10 Guide
ICD-10 CodesR41.2

R41.2

Retrograde amnesia

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

Code Description

ICD-10 R41.2 is a billable code used to indicate a diagnosis of retrograde amnesia.

Key Diagnostic Point:

Retrograde amnesia is a type of memory loss that affects the ability to recall past events, experiences, or information that occurred before the onset of amnesia. This condition can arise from various causes, including traumatic brain injury, stroke, psychological trauma, or degenerative diseases. Patients may retain the ability to form new memories but struggle to access previously stored information. Symptoms can vary in severity and may include confusion, disorientation, and difficulty recalling personal history or significant life events. Clinical evaluation often involves a thorough history and neurological examination, alongside imaging studies such as MRI or CT scans to identify any structural brain abnormalities. Neuropsychological testing may also be employed to assess the extent of memory impairment and differentiate retrograde amnesia from other cognitive disorders. Understanding the underlying cause is crucial for effective management and rehabilitation.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes
  • Need for comprehensive patient history
  • Differentiation from other types of amnesia
  • Potential overlap with psychological conditions

Audit Risk Factors

  • Inadequate documentation of the cause of amnesia
  • Failure to differentiate from other memory disorders
  • Lack of supporting clinical findings
  • Misuse of related codes leading to upcoding or downcoding

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including onset and duration of symptoms, and any relevant medical history.

Common Clinical Scenarios

Patients presenting with memory loss following a stroke or head injury.

Billing Considerations

Consideration of comorbid conditions that may affect cognitive function.

Emergency Medicine

Documentation Requirements

Acute assessment of neurological status, including Glasgow Coma Scale scores and imaging results.

Common Clinical Scenarios

Patients with acute head trauma presenting with confusion or memory loss.

Billing Considerations

Rapid assessment and documentation of potential life-threatening conditions.

Coding Guidelines

Inclusion Criteria

Use R41.2 When
  • Coders should ensure that R41
  • 2 is used only when retrograde amnesia is specifically diagnosed and documented
  • It should not be used if the memory loss is due to a known condition that has its own specific code

Exclusion Criteria

Do NOT use R41.2 When
No specific exclusions found.

Related CPT Codes

96116CPT Code

Neuropsychological testing

Clinical Scenario

Used to assess cognitive function in patients with suspected amnesia.

Documentation Requirements

Detailed results of cognitive assessments and their implications.

Specialty Considerations

May require collaboration with a psychologist or psychiatrist.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of memory disorders, including retrograde amnesia, which aids in better tracking and management of these conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of memory disorders, including retrograde amnesia, which aids in better tracking and management of these conditions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of memory disorders, including retrograde amnesia, which aids in better tracking and management of these conditions.

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 is the primary cause of retrograde amnesia?

Retrograde amnesia can be caused by various factors, including traumatic brain injury, psychological trauma, stroke, or degenerative diseases affecting the brain.

How is retrograde amnesia diagnosed?

Diagnosis typically involves a thorough patient history, neurological examination, imaging studies, and neuropsychological testing to assess memory function.