ICD Code R41.82

ICD code R41.82 is used to classify a diagnosis of altered mental status that is unspecified. This code is applied when a patient exhibits changes in cognitive function, awareness, or consciousness, but the specific cause or nature of the alteration is not clearly defined or identified. It serves as a general category for healthcare providers to document cases where mental status changes are observed, but further investigation is needed to determine the underlying condition.

When considering the use of the ICD code for altered mental status, unspecified, healthcare providers should evaluate the following diagnostic criteria and symptoms:

1. Confusion: The patient exhibits a noticeable lack of clarity in thought processes, which may manifest as difficulty in understanding or responding to questions.

2. Disorientation: The patient shows signs of being unaware of time, place, or personal identity, which can affect their ability to navigate their environment or recall recent events.

3. Memory Impairment: There is a significant decline in the patient's ability to remember recent or past events, which is not attributable to normal aging.

4. Inattention: The patient demonstrates an inability to maintain focus on tasks or conversations, often appearing distracted or easily sidetracked.

5. Altered Level of Consciousness: The patient experiences fluctuations in consciousness, ranging from drowsiness to stupor, without a clear cause.

6. Behavioral Changes: There are noticeable changes in the patient's behavior, such as agitation, lethargy, or unusual emotional responses, that cannot be explained by other conditions.

7. Cognitive Decline: A general decline in cognitive abilities, including reasoning, problem-solving, and judgment, is observed without a specific diagnosis.

8. Lack of Specific Diagnosis: The symptoms do not fit neatly into a more specific mental health or neurological disorder, necessitating the use of an unspecified code.

Healthcare providers should ensure that these symptoms are not better explained by another medical condition or substance use before assigning this ICD code.

For the ICD code R41.82 (Altered mental status, unspecified), the relevant CPT codes that might be applicable include:

1. 99201-99205 - Office or other outpatient visit for the evaluation and management of a new patient.

2. 99211-99215 - Office or other outpatient visit for the evaluation and management of an established patient.

3. 99221-99223 - Initial hospital care, per day, for the evaluation and management of a patient.

4. 99231-99233 - Subsequent hospital care, per day, for the evaluation and management of a patient.

5. 99251-99255 - Inpatient consultation for a new or established patient.

6. 96116 - Neurobehavioral status exam (clinical assessment of thinking, reasoning, and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual-spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report.

7. 96130-96133 - Psychological testing evaluation services by physician or other qualified healthcare professional, per hour.

8. 96136-96139 - Psychological or neuropsychological test administration and scoring, two or more tests, any method, per hour of the psychologist’s or physician’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.

These CPT codes are examples of services that may be performed when addressing the condition associated with ICD code R41.82. It's important for healthcare providers to select the most appropriate CPT code based on the specific services rendered and the clinical context.

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