Altered mental status, unspecified
ICD-10 R41.82 is a billable code used to indicate a diagnosis of altered mental status, unspecified.
Altered mental status (AMS) refers to a change in cognitive function, awareness, or behavior that can manifest as confusion, disorientation, lethargy, or agitation. This condition is often a symptom of an underlying medical issue rather than a standalone diagnosis. Common causes include metabolic disturbances (e.g., hypoglycemia, hypernatremia), infections (e.g., meningitis, sepsis), neurological disorders (e.g., stroke, seizures), and substance use (e.g., intoxication, withdrawal). Clinical evaluation typically involves a thorough history, physical examination, and targeted laboratory tests to identify the underlying cause. The unspecified nature of this code indicates that the specific etiology of the altered mental status has not been determined or documented, necessitating careful clinical assessment to guide appropriate management.
Detailed history and physical examination notes, including mental status examination and any relevant lab results.
Patients presenting with confusion or altered consciousness due to metabolic derangements or infections.
Ensure that any underlying conditions are documented to support the use of R41.82.
Acute care documentation must include initial assessment findings, vital signs, and any immediate interventions.
Patients presenting with acute confusion or altered consciousness due to trauma, intoxication, or acute illness.
Rapid assessment and documentation are crucial; ensure that all relevant findings are captured to justify the use of R41.82.
Used when a patient presents with altered mental status requiring immediate evaluation.
Document the patient's presenting symptoms, mental status examination, and any interventions performed.
Emergency medicine providers should ensure that all relevant findings are documented to support the visit level.
R41.82 should be used when a patient presents with altered mental status and the specific cause has not been determined or documented. It is important to ensure that all relevant clinical information is captured to support this diagnosis.
