Altered mental status remains a challenge in ICD-10-CM

Why This Topic Matters

Altered mental status is a common but nonspecific presentation that can affect diagnosis, documentation quality, and code assignment. Clear clinical specificity helps support accurate records and appropriate reporting in settings where risk adjustment and coding integrity matter.

Article Sections

1. Ascertain the nature of the altered mental status

   This section outlines broad clinical categories used to characterize altered mental status and emphasizes the importance of documenting the underlying condition. It also notes related assessment concepts used in neurology and psychiatry.

2. Determine the underlying cause of the altered mental status

   This section focuses on the major categories of underlying causes that may be associated with altered mental status. It addresses the need to identify and document the broader disease process or precipitating factor when possible.