| R40 |
Somnolence, stupor and coma [+]
| Excludes 1: |
neonatal coma (P91.5) somnolence, stupor and coma in diabetes (E08-E13) somnolence, stupor and coma in hepatic failure (K72.-) somnolence, stupor and coma in hypoglycemia (nondiabetic) (E15)
|
|
|
| R40.0 |
Somnolence Drowsiness
| Excludes 1: |
coma (R40.2-)
|
|
| R40.1 |
Stupor Catatonic stupor Semicoma
| Excludes 1: |
catatonic schizophrenia (F20.2) coma (R40.2-) depressive stupor (F31.-, F32.-, F33.-) dissociative stupor (F44.2) manic stupor (F30.2)
|
|
| R40.2 |
Coma [+]
| Note: |
One code from each subcategory, R40.21-R40.23, is required to complete the coma scale
|
| Code first |
any associated: fracture of skull (S02.-) intracranial injury (S06.-)
|
|
|
| R40.20 |
Unspecified coma Coma NOS Unconsciousness NOS
|
| R40.21 |
Coma scale, eyes open [+]
The following appropriate 7th character is to be added to subcategory R40.21-: 0 - unspecified time 1 - in the field [EMT or ambulance] 2 - at arrival to emergency department 3 - at hospital admission 4 - 24 hours or more after hospital admission
|
|
|
| R40.211 |
Coma scale, eyes open, never Coma scale eye opening score of 1
|
| R40.212 |
Coma scale, eyes open, to pain Coma scale eye opening score of 2
|
| R40.213 |
Coma scale, eyes open, to sound Coma scale eye opening score of 3
|
| R40.214 |
Coma scale, eyes open, spontaneous Coma scale eye opening score of 4
|
|
| R40.22 |
Coma scale, best verbal response [+]
The following appropriate 7th character is to be added to subcategory R40.22-: 0 - unspecified time 1 - in the field [EMT or ambulance] 2 - at arrival to emergency department 3 - at hospital admission 4 - 24 hours or more after hospital admission
|
|
|
| R40.221 |
Coma scale, best verbal response, none Coma scale verbal score of 1
|
| R40.222 |
Coma scale, best verbal response, incomprehensible words Coma scale verbal score of 2 Incomprehensible sounds (2-5 years of age) Moans/grunts to pain; restless (<2 years old)
|
| R40.223 |
Coma scale, best verbal response, inappropriate words Coma scale verbal score of 3 Inappropriate crying or screaming (< 2 years of age) Screaming (2-5 years of age)
|
| R40.224 |
Coma scale, best verbal response, confused conversation Coma scale verbal score of 4 Inappropriate words (2-5 years of age) Irritable cries (< 2 years of age)
|
| R40.225 |
Coma scale, best verbal response, oriented Coma scale verbal score of 5 Cooing or babbling or crying appropriately (< 2 years of age) Uses appropriate words (2- 5 years of age)
|
|
| R40.23 |
Coma scale, best motor response [+]
The following appropriate 7th character is to be added to subcategory R40.23-: 0 - unspecified time 1 - in the field [EMT or ambulance] 2 - at arrival to emergency department 3 - at hospital admission 4 - 24 hours or more after hospital admission
|
|
|
| R40.231 |
Coma scale, best motor response, none Coma scale motor score of 1
|
| R40.232 |
Coma scale, best motor response, extension Abnormal extensor posturing to pain or noxious stimuli (< 2 years of age) Coma scale motor score of 2 Extensor posturing to pain or noxious stimuli (2-5 years of age)
|
| R40.233 |
Coma scale, best motor response, abnormal flexion Abnormal flexure posturing to pain or noxious stimuli (2-5 years of age) Coma scale motor score of 3 Flexion/decorticate posturing (< 2 years of age)
|
| R40.234 |
Coma scale, best motor response, flexion withdrawal Coma scale motor score of 4 Withdraws from pain or noxious stimuli (2-5 years of age)
|
| R40.235 |
Coma scale, best motor response, localizes pain Coma scale motor score of 5 Localizes pain (2-5 years of age) Withdraws to touch (< 2 years of age)
|
| R40.236 |
Coma scale, best motor response, obeys commands Coma scale motor score of 6 Normal or spontaneous movement (< 2 years of age) Obeys commands (2-5 years of age)
|
|
| R40.24 |
Glasgow coma scale, total score [+]
| Note: |
Assign a code from subcategory R40.24, when only the total coma score is documented
|
The following appropriate 7th character is to be added to subcategory R40.24-: 0 - unspecified time 1 - in the field [EMT or ambulance] 2 - at arrival to emergency department 3 - at hospital admission 4 - 24 hours or more after hospital admission
|
|
|
| R40.241 |
Glasgow coma scale score 13-15
|
| R40.242 |
Glasgow coma scale score 9-12
|
| R40.243 |
Glasgow coma scale score 3-8
|
| R40.244 |
Other coma, without documented Glasgow coma scale score, or with partial score reported
|
|
| R40.2A |
Nontraumatic coma due to underlying condition Secondary coma
| Code first |
underlying condition
|
| Excludes 1: |
coma scale, best motor response (R40.24.-) coma scale, best verbal response (R40.22.-) coma scale, eyes open (R40.21.-) Glasgow coma scale, total score (R40.23.-)
|
|
|
| R40.3 |
Persistent vegetative state
|
| R40.4 |
Transient alteration of awareness
|
|
| R41 |
Other symptoms and signs involving cognitive functions and awareness [+]
| Excludes 1: |
dissociative [conversion] disorders (F44.-) mild cognitive impairment of uncertain or unknown etiology (G31.84)
|
|
|
| R41.0 |
Disorientation, unspecified Confusion NOS Delirium NOS
| Excludes 1: |
delirium due to known physiological condition (F05)
|
|
| R41.1 |
Anterograde amnesia
|
| R41.2 |
Retrograde amnesia
|
| R41.3 |
Other amnesia Amnesia NOS Memory loss NOS
| Excludes 1: |
amnestic disorder due to known physiologic condition (F04) amnestic syndrome due to psychoactive substance use (F10-F19 with 5th character .6) mild memory disturbance due to known physiological condition (F06.8) transient global amnesia (G45.4)
|
|
| R41.4 |
Neurologic neglect syndrome Asomatognosia Hemi-akinesia Hemi-inattention Hemispatial neglect Left-sided neglect Sensory neglect Visuospatial neglect
| Excludes 1: |
visuospatial deficit (R41.842)
|
|
| R41.8 |
Other symptoms and signs involving cognitive functions and awareness [+]
|
|
| R41.81 |
Age-related cognitive decline Senility NOS
|
| R41.82 |
Altered mental status, unspecified Change in mental status NOS
| Excludes 1: |
altered level of consciousness (R40.-) altered mental status due to known condition - code to condition delirium NOS (R41.0)
|
|
| R41.83 |
Borderline intellectual functioning IQ level 71 to 84
| Excludes 1: |
intellectual disabilities (F70-F79)
|
|
| R41.84 |
Other specified cognitive deficit [+]
| Code first |
the underlying condition, if known, such as: schizophrenia (F20.-)
|
| Excludes 1: |
cognitive deficits as sequelae of cerebrovascular disease (I69.01-, I69.11-, I69.21-, I69.31-, I69.81-, I69.91-)
|
|
|
| R41.840 |
Attention and concentration deficit
| Excludes 1: |
attention-deficit hyperactivity disorders (F90.-)
|
|
| R41.841 |
Cognitive communication deficit
|
| R41.842 |
Visuospatial deficit
|
| R41.843 |
Psychomotor deficit
|
| R41.844 |
Frontal lobe and executive function deficit
|
|
| R41.85 |
Anosognosia
|
| R41.89 |
Other symptoms and signs involving cognitive functions and awareness
|
|
| R41.9 |
Unspecified symptoms and signs involving cognitive functions and awareness Unspecified neurocognitive disorder
|
|
| R42 |
Dizziness and giddiness Light-headedness Vertigo NOS
| Excludes 1: |
vertiginous syndromes (H81.-) vertigo from infrasound (T75.23)
|
|
| R43 |
Disturbances of smell and taste [+]
|
|
| R43.0 |
Anosmia
|
| R43.1 |
Parosmia
|
| R43.2 |
Parageusia
|
| R43.8 |
Other disturbances of smell and taste Mixed disturbance of smell and taste
|
| R43.9 |
Unspecified disturbances of smell and taste
|
|
| R44 |
Other symptoms and signs involving general sensations and perceptions [+]
| Excludes 1: |
alcoholic hallucinations (F10.151, F10.251, F10.951) hallucinations in drug psychosis (F11-F19 with fifth to sixth characters 51) hallucinations in mood disorders with psychotic symptoms (F30.2, F31.5, F32.3, F33.3) hallucinations in schizophrenia, schizotypal and delusional disorders (F20-F29)
|
| Excludes 2: |
disturbances of skin sensation (R20.-)
|
|
|
| R44.0 |
Auditory hallucinations
|
| R44.1 |
Visual hallucinations
|
| R44.2 |
Other hallucinations
|
| R44.3 |
Hallucinations, unspecified
|
| R44.8 |
Other symptoms and signs involving general sensations and perceptions
|
| R44.9 |
Unspecified symptoms and signs involving general sensations and perceptions
|
|
| R45 |
Symptoms and signs involving emotional state [+]
|
|
| R45.0 |
Nervousness Nervous tension
|
| R45.1 |
Restlessness and agitation
|
| R45.2 |
Unhappiness
|
| R45.3 |
Demoralization and apathy
| Excludes 1: |
anhedonia (R45.84)
|
|
| R45.4 |
Irritability and anger
|
| R45.5 |
Hostility
|
| R45.6 |
Violent behavior
|
| R45.7 |
State of emotional shock and stress, unspecified
|
| R45.8 |
Other symptoms and signs involving emotional state [+]
|
|
| R45.81 |
Low self-esteem
|
| R45.82 |
Worries
|
| R45.83 |
Excessive crying of child, adolescent or adult
| Excludes 1: |
excessive crying of infant (baby) R68.11
|
|
| R45.84 |
Anhedonia
|
| R45.85 |
Homicidal and suicidal ideations [+]
| Excludes 1: |
suicide attempt (T14.91)
|
|
|
|
| R45.86 |
Emotional lability
|
| R45.87 |
Impulsiveness
|
| R45.88 |
Nonsuicidal self-harm Nonsuicidal self-injury Nonsuicidal self-mutilation Self-inflicted injury without suicidal intent
| Code also |
injury, if known
|
|
| R45.89 |
Other symptoms and signs involving emotional state Flat affect Loneliness
|
|
|
| R46 |
Symptoms and signs involving appearance and behavior [+]
| Excludes 1: |
appearance and behavior in schizophrenia, schizotypal and delusional disorders (F20-F29) mental and behavioral disorders (F01-F99)
|
|
|
| R46.0 |
Very low level of personal hygiene
|
| R46.1 |
Bizarre personal appearance
|
| R46.2 |
Strange and inexplicable behavior
|
| R46.3 |
Overactivity
|
| R46.4 |
Slowness and poor responsiveness
| Excludes 1: |
stupor (R40.1)
|
|
| R46.5 |
Suspiciousness and marked evasiveness
|
| R46.6 |
Undue concern and preoccupation with stressful events
|
| R46.7 |
Verbosity and circumstantial detail obscuring reason for contact
|
| R46.8 |
Other symptoms and signs involving appearance and behavior [+]
|
|
| R46.81 |
Obsessive-compulsive behavior
| Excludes 1: |
obsessive-compulsive disorder (F42.-)
|
|
| R46.89 |
Other symptoms and signs involving appearance and behavior
|
|
|