Symptoms & Signs (R Codes)

R41.82 ICD-10-CM

Altered mental status, unspecified

Category

Symptoms & Signs (R Codes)

Billing status

Billable / specific code

Billable

Code set

ICD-10-CM diagnosis

ICD-10-CM code R41.82 describes altered mental status, unspecified. Symptom-level code for changes in mental status; document underlying cause when known. It is a billable, specific code valid for claim submission. It is grouped under the “Symptoms & Signs (R Codes)” section of the mental, behavioral, and neurodevelopmental disorders chapter.

When to use R41.82

R codes report symptoms, signs, or ill-defined findings such as suicidal ideation, irritability, or cognitive deficits when no definitive diagnosis has been established. They are frequently secondary to a documented mental health diagnosis. For R41.82 specifically, symptom-level code for changes in mental status; document underlying cause when known.

Documentation & billing

Document the symptom and any workup to date. Once diagnostic criteria are met, use a definitive mental disorder code rather than relying indefinitely on a symptom code.

Common pitfalls

  • Using a symptom R code when a definitive diagnosis is already documented.
  • Coding suicidal ideation (R45.84) without a corresponding risk assessment and safety plan.
  • Relying on R codes long-term instead of establishing a diagnosis.

Common search terms for R41.82

Clinicians often look up R41.82 using plain-language terms. This code maps to:

altered mental status
confusion
AMS

Frequently asked questions

What is ICD-10-CM code R41.82?

Altered mental status, unspecified. Symptom-level code for changes in mental status; document underlying cause when known.

Is R41.82 a billable ICD-10-CM code?

Yes. R41.82 (Altered mental status, unspecified) is a billable, specific ICD-10-CM code that can be reported on a claim. Confirm the current official descriptor against the CDC code set and your payer’s policies before submitting.

What should I document to support R41.82?

Document the symptom and any workup to date. Once diagnostic criteria are met, use a definitive mental disorder code rather than relying indefinitely on a symptom code.

Related Symptoms & Signs (R Codes) codes

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