Find information on Transient Alteration of Awareness, including clinical documentation tips, medical coding guidelines, and differential diagnosis considerations. Learn about altered level of consciousness, altered mental status, delirium, confusion, and encephalopathy as they relate to transient alterations in awareness. Explore resources for healthcare professionals on accurately documenting and coding these episodes for optimal patient care and reimbursement. This resource covers transient neurological events, altered perception, and cognitive impairment related to transient changes in awareness.
Also known as
Symptoms and signs involving cognition, perception, emotional state and behaviour
Covers various mental and behavioral symptoms, including altered awareness.
Epilepsy and other seizure disorders
Includes conditions that can cause transient alterations of awareness, such as seizures.
Delirium, other acute cognitive disorders
Encompasses conditions causing temporary cognitive impairment, including altered awareness.
General symptoms and signs
May include codes for nonspecific symptoms like altered awareness if a more specific cause isn't identified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the alteration of awareness due to a physical condition?
Yes
Is it due to a metabolic disturbance?
No
Is it a syncopal episode?
When to use each related code
| Description |
|---|
| Transient change in awareness |
| Delirium |
| Encephalopathy |
Using unspecified codes like R41.89 when more specific documentation supports codes like R40.0-R40.2 risks inaccurate reimbursement and data.
Conditions like epilepsy or syncope may mimic TAA, leading to incorrect TAA coding instead of the primary diagnosis, impacting quality metrics.
Insufficient documentation of symptom duration, onset, or resolution for TAA can lead to coding denials and compliance issues with clinical validation.
Patient presents with a transient alteration of awareness, characterized by a sudden, brief change in mental status. Differential diagnoses considered included seizure, syncope, metabolic disturbance, and transient ischemic attack. Symptoms reported include altered perception, confusion, disorientation, and possible amnesia regarding the event. Onset was sudden, duration was brief (approximately [duration]), and resolution was spontaneous and complete. No residual neurological deficits were noted. The patient denies any history of similar events. Physical examination revealed normal neurological findings. Vital signs were stable throughout the encounter. Laboratory studies, including complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis (UA) were within normal limits. Electrocardiogram (ECG) showed normal sinus rhythm. Based on the clinical presentation, history, and absence of other findings, the diagnosis of transient alteration of awareness is made. The patient was educated on possible triggers and instructed to return for further evaluation if symptoms recur or worsen. Follow-up is recommended as needed. ICD-10 code R41.89 (Other symptoms and signs involving cognitive functions and awareness) is considered. This diagnosis is provisional pending further investigation if symptoms persist or recur.