Restlessness and agitation

This code signifies a state of motor restlessness and heightened emotional or psychological tension. Patients may exhibit an inability to remain still, fidgeting, pacing, or an increased level of irritability and anxiety. It reflects a symptom, not a definitive diagnosis, often indicative of an underlying medical or psychiatric condition.

Apply this code when documentation explicitly states "restlessness and agitation" as a presenting symptom or a component of a patient's clinical picture, without a more specific underlying cause yet identified or coded. It is appropriate for acute presentations in various settings, including emergency departments, inpatient, and outpatient encounters. Documentation should clearly describe both the restless motor activity and the agitated emotional state.

• Do not use this code as a primary diagnosis if a more specific underlying cause for the restlessness and agitation (e.g., delirium, anxiety disorder, drug withdrawal) is documented and can be coded.
• Consider sequencing this code after the primary condition if the restlessness and agitation are manifestations of that condition.
• Differentiate from "nervousness" (R45.0) or "anxiety, unspecified" (F41.9), as this code specifically implies both motor and emotional components.