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ICD-10 Guide
ICD-10 CodesR41.84

R41.84

Other specified cognitive deficit

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

Code Description

ICD-10 R41.84 is a billable code used to indicate a diagnosis of other specified cognitive deficit.

Key Diagnostic Point:

R41.84 is used to classify cognitive deficits that do not fall under more specific categories. Cognitive deficits can manifest as difficulties in memory, attention, problem-solving, and other cognitive functions. Patients may present with symptoms such as confusion, disorientation, impaired judgment, or difficulty in learning new information. These deficits can arise from various underlying conditions, including neurological disorders, psychiatric conditions, or as a result of substance abuse. Clinical evaluation often includes a thorough history, cognitive assessments, and possibly neuroimaging or laboratory tests to rule out other causes. The diagnosis of 'Other specified cognitive deficit' is typically made when the cognitive impairment is significant enough to warrant attention but does not meet the criteria for more defined cognitive disorders such as dementia or delirium.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying causes leading to cognitive deficits.
  • Overlap with other cognitive disorder codes.
  • Need for comprehensive documentation to support diagnosis.
  • Potential for misclassification with similar codes.

Audit Risk Factors

  • Insufficient documentation of cognitive deficits.
  • Failure to specify the underlying cause of cognitive impairment.
  • Inconsistent use of the code across different encounters.
  • Lack of supporting clinical evidence for the diagnosis.

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, cognitive assessment results, and any relevant lab or imaging findings.

Common Clinical Scenarios

Patients presenting with vague cognitive complaints, such as forgetfulness or confusion, without a clear diagnosis.

Billing Considerations

Ensure that the cognitive deficits are documented as significant enough to impact daily functioning.

Emergency Medicine

Documentation Requirements

Acute assessment findings, including mental status exams and any immediate interventions.

Common Clinical Scenarios

Patients presenting with acute confusion or altered mental status due to various causes.

Billing Considerations

Document the acute nature of the cognitive deficit and any immediate treatment provided.

Coding Guidelines

Inclusion Criteria

Use R41.84 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation and that the cognitive deficits are clearly described

Exclusion Criteria

Do NOT use R41.84 When
No specific exclusions found.

Related CPT Codes

96116CPT Code

Neuropsychological testing

Clinical Scenario

Used when cognitive deficits are assessed through formal testing.

Documentation Requirements

Document the type of tests performed and the results.

Specialty Considerations

Ensure that the testing aligns with the cognitive deficits being evaluated.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cognitive deficits, improving the ability to capture the nuances of cognitive impairments and their underlying causes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cognitive deficits, improving the ability to capture the nuances of cognitive impairments and their underlying causes.

Reimbursement & Billing Impact

impact on the patient's daily life, and any relevant assessments or treatments provided.

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 be documented to support the use of R41.84?

Documentation should include a detailed description of the cognitive deficits, results from cognitive assessments, and any relevant medical history or underlying conditions.