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)
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R40.0 |
Somnolence Drowsiness
Excludes 1: |
coma (R40.2-)
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R40.1 |
Stupor Catatonic stupor Semicoma
Excludes 1: |
catatonic schizophrenia (F20.2) coma (R40.2-) depressive stupor (F31-F33) dissociative stupor (F44.2) manic stupor (F30.2)
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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.-)
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R40.20 |
Unspecified coma Coma NOS Unconsciousness NOS
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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
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R40.211 |
Coma scale, eyes open, never Coma scale eye opening score of 1
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R40.212 |
Coma scale, eyes open, to pain Coma scale eye opening score of 2
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R40.213 |
Coma scale, eyes open, to sound Coma scale eye opening score of 3
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R40.214 |
Coma scale, eyes open, spontaneous Coma scale eye opening score of 4
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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
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R40.221 |
Coma scale, best verbal response, none Coma scale verbal score of 1
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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)
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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)
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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)
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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)
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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
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R40.231 |
Coma scale, best motor response, none Coma scale motor score of 1
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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)
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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)
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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)
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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)
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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)
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R40.24 |
Glasgow coma scale, total score [+]
Note: |
Assign a code from subcategory R40.24, when only the total coma score is documented
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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
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R40.241 |
Glasgow coma scale score 13-15
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R40.242 |
Glasgow coma scale score 9-12
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R40.243 |
Glasgow coma scale score 3-8
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R40.244 |
Other coma, without documented Glasgow coma scale score, or with partial score reported
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R40.2A |
Nontraumatic coma due to underlying condition Secondary coma
Code first |
underlying condition
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R40.3 |
Persistent vegetative state
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R40.4 |
Transient alteration of awareness
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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)
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R41.0 |
Disorientation, unspecified Confusion NOS Delirium NOS
Excludes 1: |
delirium due to known physiological condition (F05)
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R41.1 |
Anterograde amnesia
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R41.2 |
Retrograde amnesia
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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)
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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)
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R41.8 |
Other symptoms and signs involving cognitive functions and awareness [+]
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R41.81 |
Age-related cognitive decline Senility NOS
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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)
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R41.83 |
Borderline intellectual functioning IQ level 71 to 84
Excludes 1: |
intellectual disabilities (F70-F79)
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R41.84 |
Other specified cognitive deficit [+]
Code first |
the underlying condition, if known, such as: schizophrenia (F20.-)
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Excludes 1: |
cognitive deficits as sequelae of cerebrovascular disease (I69.01-, I69.11-, I69.21-, I69.31-, I69.81-, I69.91-)
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R41.840 |
Attention and concentration deficit
Excludes 1: |
attention-deficit hyperactivity disorders (F90.-)
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R41.841 |
Cognitive communication deficit
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R41.842 |
Visuospatial deficit
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R41.843 |
Psychomotor deficit
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R41.844 |
Frontal lobe and executive function deficit
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R41.85 |
Anosognosia
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R41.89 |
Other symptoms and signs involving cognitive functions and awareness
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R41.9 |
Unspecified symptoms and signs involving cognitive functions and awareness Unspecified neurocognitive disorder
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R42 |
Dizziness and giddiness Light-headedness Vertigo NOS
Excludes 1: |
vertiginous syndromes (H81.-) vertigo from infrasound (T75.23)
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R43 |
Disturbances of smell and taste [+]
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|
R43.0 |
Anosmia
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R43.1 |
Parosmia
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R43.2 |
Parageusia
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R43.8 |
Other disturbances of smell and taste Mixed disturbance of smell and taste
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R43.9 |
Unspecified disturbances of smell and taste
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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)
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Excludes 2: |
disturbances of skin sensation (R20.-)
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R44.0 |
Auditory hallucinations
|
R44.1 |
Visual hallucinations
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R44.2 |
Other hallucinations
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R44.3 |
Hallucinations, unspecified
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R44.8 |
Other symptoms and signs involving general sensations and perceptions
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R44.9 |
Unspecified symptoms and signs involving general sensations and perceptions
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R45 |
Symptoms and signs involving emotional state [+]
|
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R45.0 |
Nervousness Nervous tension
|
R45.1 |
Restlessness and agitation
|
R45.2 |
Unhappiness
|
R45.3 |
Demoralization and apathy
Excludes 1: |
anhedonia (R45.84)
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|
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)
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|
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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
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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)
|
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|
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.-)
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R46.89 |
Other symptoms and signs involving appearance and behavior
|
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