Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 1

By James Kennedy, MD, CCS, CDIP

In ICD-10-CM, defining, diagnosing, and documenting the various forms of altered mental status and their underlying causes remains an ongoing challenge for physicians and their facilities.

Even the esteemed New England Journal of Medicine states that, “‘Altered mental status,’ a nonspecific term that is frequently used to describe alterations in alertness, cognition, or behavior, is commonly encountered in the emergency setting.” If you have a subscription or access through your medical library, review the discussion at www.nejm.org/doi/full/10.1056/NEJMcps1603154.

In addressing altered mental states, we must embrace definitions in Diagnostic and Statistical Manual, 5th Edition (DSM-5), available at http://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596, and standard neurology texts (such as Adams and Victor Principles of Neurology, 10th Edition [Adams and Victor], available at http://accessmedicine.mhmedical.com/book.aspx?bookid=690), and document our patient’s conditions based on these definitions in our notes followed by the suspected underlying brain pathology or pathophysiology. These include (with their references):

• Delirium. A disturbance in attention and awareness that develops over a short period, represents a change in baseline, tends to fluctuate, and is associated with cognitive disturbances that cannot be explained by a preexisting or evolving neurocognitive disorder and is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, toxin exposure, or other multiple etiologies. Reference: DSM-5. Note: ICD-10-CM considers “sundowning” to be a delirium; however, the underlying neurocognitive disorder should be ascertained and documented.
• Psychosis. Delusions, hallucinations, or disordered speech that may occur with grossly disorganized or catatonic behavior. Reference: DSM-5.
• Dementia, also known as a major neurocognitive disorder. A significant cognitive decline (e.g., complex attention, executive function, learning, memory, language) that interferes with independence in everyday activity and that does not occur in the context of a delirium, major depressive disorder, or schizophrenia. Reference: DSM-5. Note: Dementia may be associated with significant behavioral changes, which, if documented and attributed to the dementia, add relative weight in risk adjustment methodologies.
• Persistent vegetative state. An unresponsive and, for the most part, unconscious patient (usually after brain injury) who does not speak, shows no signs of awareness of the environment or inner need, and whose motor activity is limited to primitive postural and reflex movements of the limbs with loss of sphincter control. There might be arousal or wakefulness in alternating cycles as reflected in partial eye opening, but the patient regains neither awareness nor purposeful behavior. Reference: Adams and Victor.
• Minimally conscious state (MCS). A patient who is capable of some rudimentary behavior such as following a simple command, gesturing, or producing single words or brief phrases, always in an inconsistent way from one examination to another. Reference: Adams and Victor. Note: There is no code for MCS in ICD-10-CM; as such, use other language to describe this condition.
• Stupor. Also known as semi-coma in ICD-10-CM, lack of psychomotor activity (Reference: DSM-5), or a state in which the patient can be roused only by vigorous and repeated stimuli and in which arousal cannot be sustained without repeated stimulation. Reference: Adams and Victor.
• Coma. Also known as unconsciousness in ICD-10-CM, a patient who is incapable of being aroused by external stimuli or inner need.
• Glasgow Coma Scale. A defined scale of altered levels of consciousness in adults and pediatrics that may be coded in ICD-10-CM if documented by an EMT, nurse, or another clinician. The Glasgow Coma Scale should be part of any altered mental status evaluation.

There are other neurological or psychiatric terms (e.g., amnestic disorder, mood disorders, personality disorders) describing altered mental states that should be diagnosed and documented when encountered. Don’t forget to mention if these are acute or chronic as well.

Editor’s note: Dr. Kennedy is the president of CDI MD, a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. This article originally appeared in the Revenue Cycle Advisor.