Altered mental status, unspecified

This code signifies a change in a patient's usual mental state, characterized by a general decline in cognitive function, awareness, or behavior. It represents a broad, non-specific presentation where the underlying cause of the mental status alteration is not yet determined or documented.

Use this code when documentation indicates a patient presents with a change in mental status, such as confusion, disorientation, or unusual behavior, but the specific etiology (e.g., infection, metabolic imbalance, medication effect) is unknown. It is appropriate for initial encounters or when the physician has not yet established a definitive diagnosis for the altered mental state.

• Do not use this code if the documentation specifies an altered level of consciousness (e.g., somnolence, stupor, coma); refer to the R40.- series.
• Avoid this code if the altered mental status is clearly attributable to a known underlying condition; instead, code the specific condition.
• This code should generally be considered a temporary diagnosis; strive for greater specificity once the cause of the altered mental status is identified.