For example, patients with coma are different. Altered mental status is a broad category that applies to geriatric patients who have a change in cognition or level of consciousness (LOC). AMS ranges from slight confusion to total disorientation and increased sleepiness to coma. But not all altered mental status is the same The presence of AMS is not as important as the type of AMS. This change can happen suddenly or over days. toxic encephalopathy, anoxic encephalopathy) can be coded. Altered mental status (AMS) is a disruption in how your brain works that causes a change in behavior. School Indian River State College Course Title MEDICAL 101 Uploaded By ChancellorTeamPuppy. A patient with an altered mental status has. acute or chronic delirium, dementia, coma) and the underlying cause (e.g. A patient with an altered mental status has experienced A a gradual decrease in. Given that most of the specified altered mental statuses vary with differing types of encephalopathy, I believe that if these three elements of CDI review are answered that both the manifestation (e.g. Acute changes in mental status are more concerning and are. Linkage of the cause and effect of these two condition Altered mental status is a common chief complaint among older emergency department (ED) patients.The nature of the encephalopathy: Options include hypertensive, metabolic, anoxic, toxic, hepatic, etc. It is characterized by fever, rigidity, and altered mental status (eg, agitated delirium, confusion, mutism, or catatonia).The nature of the altered mental status: Options include dementia, delirium, psychosis, stupor, coma, etc. Given that R41.82 is a Chapter 18 symptom code, given that the ICD-10-CM Official Guidelines for Coding and Reporting state that “ Signs and symptoms that are associated routinely associated with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” and given that an altered mental status is integral to having an encephalopathy, I would only report G93.40.Īfter CDI Effort: CDI specialists need to obtain the specificity of the following: R41.82 altered mental status, unspecified The patient’s altered mental status warrants a computerized tomography (CT) scan of the head to assess for bleeding or other abnormalities of the brain. #A PATIENT WITH AN ALTERED MENTAL STATUS IS CODE#Q: Can we code altered mental status as a manifestation and encephalopathy together?Ī: In answering the question, we must consider what is documented before or after the CDI effort.īefore CDI Effort: If all that is documented is “altered mental status” and “encephalopathy,” I would assign the following two codes:
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