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  4. R40-R46
  5. Other symptoms and signs involving cognitive functions and awareness (R41)

Other symptoms and signs involving cognitive functions and awareness (R41)

The ICD-10 code section R41 addresses various symptoms and signs involving cognitive functions and awareness. It is used to classify diverse cognitive disturbances such as memory loss, confusion, and altered mental states that do not fit into more specific neurological diagnoses.

This section includes important codes like R41.0 for disorientation, commonly referred to by terms such as acute or chronic confusion and delirium, as well as R41.1 and R41.2 for anterograde and retrograde amnesia, which involve difficulties with forming new memories or recalling past events. Other notable codes cover conditions like R41.4 (neurologic neglect syndrome, or anosognosia), representing a lack of awareness of deficits, and R41.81 for age-related cognitive decline, often associated with senility. The section also encompasses deficits in attention (R41.840), cognitive communication (R41.841), visuospatial skills (R41.842), psychomotor function (R41.843), and executive functions (R41.844). Additionally, R41.82 captures unspecified altered mental status, reflecting a broad range of mental impairments.

Medical coders can use this section to identify codes for symptoms like confusion, amnesia, and cognitive deficits that are critical for clinical documentation and patient care, especially when the exact neurological cause is not confirmed. Understanding synonyms such as “delirium,” “memory lapses,” or “mental confusion” helps clinicians precisely select the appropriate ICD-10 code for documenting cognitive and awareness-related signs and symptoms.

Instructional Notations

Type 1 Excludes

A type 1 excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

  • dissociative [conversion] disorders F44
  • mild cognitive impairment of uncertain or unknown etiology G31.84

Clinical Terms

The following clinical terms provide additional context, helping users better understand the clinical background and common associations for each diagnosis listed in this section. Including related terms alongside ICD-10-CM codes supports coders, billers, and healthcare professionals in improving accuracy, enhancing documentation, and facilitating research or patient education.

Akinetic Mutism

A syndrome characterized by a silent and inert state without voluntary motor activity despite preserved sensorimotor pathways and vigilance. Bilateral FRONTAL LOBE dysfunction involving the anterior cingulate gyrus and related brain injuries are associated with this condition. This may result in impaired abilities to communicate and initiate motor activities. (From Adams et al., Principles of Neurology, 6th ed, p348; Fortschr Neurol Psychiatr 1995 Feb;63(2):59-67)

Alcohol Withdrawal Delirium

An acute organic mental disorder induced by cessation or reduction in chronic alcohol consumption. Clinical characteristics include CONFUSION; DELUSIONS; vivid HALLUCINATIONS; TREMOR; agitation; insomnia; and signs of autonomic hyperactivity (e.g., elevated blood pressure and heart rate, dilated pupils, and diaphoresis). This condition may occasionally be fatal. It was formerly called delirium tremens. (From Adams et al., Principles of Neurology, 6th ed, p1175)

Alien Limb Phenomenon

An apraxia characterized by the affected limb having involuntary, autonomous, and seemingly purposeful behaviors that are perceived as being controlled by an external force. Often the affected limb interferes with the actions of the normal limb. Symptoms develop from lesions in the CORPUS CALLOSUM or medial frontal cortex caused by stroke, infarction, and neurodegenerative diseases (e.g., CREUTZFELDT-JAKOB SYNDROME, corticobasal degeneration).

Amnesia

Pathologic partial or complete loss of the ability to recall past experiences (AMNESIA, RETROGRADE) or to form new memories (AMNESIA, ANTEROGRADE). This condition may be of organic or psychologic origin. Organic forms of amnesia are usually associated with dysfunction of the DIENCEPHALON or HIPPOCAMPUS. (From Adams et al., Principles of Neurology, 6th ed, pp426-7)

Amnesia, Anterograde

Loss of the ability to form new memories beyond a certain point in time. This condition may be organic or psychogenic in origin. Organically induced anterograde amnesia may follow CRANIOCEREBRAL TRAUMA; SEIZURES; ANOXIA; and other conditions which adversely affect neural structures associated with memory formation (e.g., the HIPPOCAMPUS; FORNIX (BRAIN); MAMMILLARY BODIES; and ANTERIOR THALAMIC NUCLEI). (From Memory 1997 Jan-Mar;5(1-2):49-71)

Amnesia, Retrograde

Loss of the ability to recall information that had been previously encoded in memory prior to a specified or approximate point in time. This process may be organic or psychogenic in origin. Organic forms may be associated with CRANIOCEREBRAL TRAUMA; CEREBROVASCULAR ACCIDENTS; SEIZURES; DEMENTIA; and a wide variety of other conditions that impair cerebral function. (From Adams et al., Principles of Neurology, 6th ed, pp426-9)

Amnesia, Transient Global

A syndrome characterized by a transient loss of the ability to form new memories. It primarily occurs in middle aged or elderly individuals, and episodes may last from minutes to hours. During the period of amnesia, immediate and recent memory abilities are impaired, but the level of consciousness and ability to perform other intellectual tasks are preserved. The condition is related to bilateral dysfunction of the medial portions of each TEMPORAL LOBE. Complete recovery normally occurs, and recurrences are unusual. (From Adams et al., Principles of Neurology, 6th ed, pp429-30)

Catastrophization

Cognitive and emotional processes encompassing magnification of pain-related stimuli, feelings of helplessness, and a generally pessimistic orientation.

Countertransference

Conscious or unconscious emotional reaction of the therapist to the patient which may interfere with treatment. (APA, Thesaurus of Psychological Index Terms, 8th ed.)

Delirium

A disorder characterized by CONFUSION; inattentiveness; disorientation; ILLUSIONS; HALLUCINATIONS; agitation; and in some instances autonomic nervous system overactivity. It may result from toxic/metabolic conditions or structural brain lesions. (From Adams et al., Principles of Neurology, 6th ed, pp411-2)

Emergence Delirium

A form of DELIRIUM which occurs after GENERAL ANESTHESIA.

Frontal Lobe

The part of the cerebral hemisphere anterior to the central sulcus, and anterior and superior to the lateral sulcus.

Neurocognitive Disorders

Diagnoses of DEMENTIA and AMNESTIC DISORDER are subsumed here. (DSM-5)

Prejudice

A preconceived judgment made without factual basis.

Racism

Differential treatment or unequal access to opportunities, based on group membership such as origin or ethnicity.

Sepsis-Associated Encephalopathy

Acute neurological dysfunction during severe SEPSIS in the absence of direct brain infection characterized by systemic inflammation and BLOOD BRAIN BARRIER perturbation.

Temporal Lobe

Lower lateral part of the cerebral hemisphere responsible for auditory, olfactory, and semantic processing. It is located inferior to the lateral fissure and anterior to the OCCIPITAL LOBE.

Weight Prejudice

Negative attitudes towards and beliefs about others because of their weight. These negative attitudes are manifested by stereotypes and/or prejudice towards people with weight over or under a cultural norm.