What is the ICD-10 code for altered level of consciousness?

The primary ICD-10 codes for altered level of consciousness are R40.0 for somnolence, R40.1 for stupor, and R40.2 for coma.

How do you document altered level of consciousness?

Document the patient's GCS score, response to stimuli, and any underlying conditions causing the altered consciousness.

ICD-10 Coding for Altered Level of Consciousness(R40.0, R40.1, R40.2)

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Explore ICD-10 codes for altered level of consciousness, including documentation requirements and coding tips for somnolence, stupor, and coma.

Also known as:

ALOCAltered ConsciousnessImpaired Consciousness

Related ICD-10 Code Ranges

Complete code families applicable to Altered Level of Consciousness

R00-R99Primary Range

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

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Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

Code	Description	When to Use	Key Documentation
R40.0	Somnolence	Use when the patient is drowsy but can be aroused with verbal stimuli.	Patient is drowsy but arousable with verbal stimuli.
R40.1	Stupor	Use when the patient is unresponsive except to vigorous stimuli.	Patient is unresponsive except to vigorous stimuli.
R40.2	Coma	Use when the patient is completely unresponsive.	Patient is completely unresponsive with a GCS ≤8.

Primary ICD-10-CM Codes

Somnolence

R40.0Billable

Differential Codes

Alternative codes to consider when ruling out similar conditions

Altered mental status, unspecifiedR41.82

ComaR40.2

StuporR40.1

Documentation & Coding Risks

Avoid these common issues when documenting Altered Level of Consciousness.

Omitting GCS score

Impact

Clinical: Inadequate assessment of consciousness level., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.

Mitigation

Ensure GCS score is documented in all cases of ALOC.

Using R41.82 for altered consciousness

Impact

Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Impacts accuracy of patient records.

Mitigation

Use R40.- codes for altered level of consciousness.

Incorrect coding of consciousness level

Impact

Using incorrect codes for the level of consciousness can lead to audits.

Mitigation

Ensure accurate documentation of the patient's response to stimuli and GCS score.

Frequently Asked Questions

Documentation requirements, coding pitfalls and FAQs for conditions coded with R40.0.

Primary Code

R40.0

Somnolence

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ICD-10 codes4

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ICD-10 Coding for Altered Level of Consciousness(R40.0, R40.1, R40.2)

Documentation & Coding Risks

Frequently Asked Questions

What is the ICD-10 code for altered level of consciousness?

How do you document altered level of consciousness?

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