Dementia ICD-10 CM coding Guide for coders

Basic information about ICD-10 CM code for Dementia

Dementia is characterized by the development of multiple cognitive deficits such as memory impairment and cognitive disturbances including aphasia, apraxia, and agnosia. The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology (i.e., vascular, other diseases classified elsewhere, unspecified) and severity (i.e., unspecified, mild, moderate, or severe). The severity level should only be assigned on the basis of provider documentation, unless otherwise instructed by the classification. When a patient admitted to an inpatient acute care hospital or other inpatient facility setting progresses to a higher severity level, assign one code for the highest severity level documented during the stay.. ICD-Code F03.90 is a billable ICD-10 code used for Unspecified Dementia without Behavioral Disturbance. Its corresponding ICD-9 code is 294.2.

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Description of Dementia ICD-10 CM codes

Dementia is characterized by the development of multiple cognitive deficits such as memory impairment and cognitive disturbances including aphasia, apraxia, and agnosia. The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology (i.e., vascular, other diseases classified elsewhere, unspecified) and severity (i.e., unspecified, mild, moderate, or severe). The severity level should only be assigned on the basis of provider documentation, unless otherwise instructed by the classification. When a patient admitted to an inpatient acute care hospital or other inpatient facility setting progresses to a higher severity level, assign one code for the highest severity level documented during the stay.

Fifth and sixth-characters for categories F01, F02 and F03 specify the presence or absence of behavioral disturbances such as agitation, psychotic disturbance, mood disturbance, anxiety, and other behavioral disturbance. It is important to review Tabular List inclusion notes for expanded examples of behavioral disturbances. For example, for subcategory F01.51-, behavioral disturbances classified to code F01.511,Vascular dementia, unspecified severity, with agitation, include:

• Aberrant motor behavior such as restlessness, rocking, pacing, or exit-seeking
• Verbal or physical behaviors such as profanity, shouting, threatening, anger, aggression, combativeness, or violence

Examples of “other behavioral disturbances” classified to code F01.518, Vascular dementia, unspecified severity, with other behavioral disturbance, include sleep disturbance, social disinhibition, and sexual disinhibition.

Category F02 classifies dementia due to direct physiological effects of a general medical condition and includes major neurocognitive disorders in other diseases classified elsewhere. When assigning codes from category F02, code first the underlying physiological condition associated with the dementia, such as Alzheimer’s disease (G30.-) or Parkinson’s disease (G20). When the cause of the dementia is not specified, the dementia is classified to category F03, Unspecified dementia. If the patient has a tendency to wander off, code Z91.83, Wandering in diseases classified elsewhere, may be assigned in addition to a code from categories F01–F03 for dementia with other behavioral disturbance (final characters 18), such as F01.B18, Vascular dementia, moderate, with other behavioral disturbance.

F03 Unspecified dementia
Presenile dementia NOS
Presenile psychosis NOS
Primary degenerative dementia NOS
Senile dementia NOS
Senile dementia depressed or paranoid type
Senile psychosis NOS
Excludes1: senility NOS (R41.81)
Excludes2: mild memory disturbance due to known physiological condition (F06.8)
senile dementia with delirium or acute confusional state (F05)

F03.9 Unspecified dementia
F03.90 Unspecified dementia without behavioral disturbance 52
Dementia NOS
F03.91 Unspecified dementia with behavioral disturbance 51
Unspecified dementia with aggressive behavior
Unspecified dementia with combative behavior
Unspecified dementia with violent behavior
Use additional code, if applicable, to identify wandering in unspecified dementia (Z91.83)

New subcategories have been created with new codes under categories F01, Vascular Dementia, F02, Dementia in other diseases classified elsewhere, and F03, Unspecified Dementia.

Vascular dementia (F01.511-F01.C4)
Dementia in other diseases classified elsewhere (F02.811-F02.C4)
Unspecified dementia (F03.911-F03.C4)

Sixty-nine new codes have been created under these categories to recognize the stages of severity and to identify the behavioral and psychological symptoms of dementia (BPSD).

Applicable stages (or types)
Dementia can progress and worsen over time. Early signs of the condition include misplacing items, getting lost on familiar routes, personality changes, flat mood, and difficulty performing simple tasks. As the dementia worsens, the patient may forget details about current events, forget events in his or her own history, have difficulty reading or writing, or even have hallucinations. Those with severe dementia cannot understand language, perform basic activities of daily living, or recognize family members.

Symptoms
Dementia is characterized by the development of multiple cognitive deficits, such as memory impairment, functional impairment, and cognitive disturbances, such as aphasia, apraxia, or agnosis.

Other symptoms may include difficulty with the following:

• Language
• Memory
• Perception
• Emotional behavior or personality
• Cognitive skills (e.g., calculation, abstract thinking, or judgment)

Treatment
Treatment depends on the condition causing the dementia (e.g., anemia, decreased oxygen, depression, heart failure, infection, nutritional disorders, thyroid disorders). Some medications may help control behavior problems. Psychotherapy or group therapy is usually not effective because it causes more confusion.

The following are types of untreatable causes of dementia:

• Alzheimer’s disease
• Multi-infarct dementia (dementia due to multiple small strokes)
• Dementias associated with Parkinson’s disease and similar disorders
• AIDS dementia complex
• Creutzfeldt-Jakob disease (CJD), a quickly progressing and fatal disease that consists of dementia and muscle twitching and spasm

Documentation and coding

Dementia is often a symptom of something else, such as Generalized Cerebrovascular Ischemia, Alzheimer’s disease, or toxic effects of drugs. Coders may need to ask the physician to identify the likely cause of the patient’s presentation and query to address treatment or care to that cause. The documentation should identify clearly the relationship in the medical record. Ask for the specific reason or cause relationship of the dementia. There may be times when the dementia is related to an infection, sepsis, dehydration, or specific organ failure. If necessary, query the physician to obtain clarifying documentation that addresses the specific reason for cause relationship between a condition and the mental status change.

Remember the coding guidelines, which state that when assigning codes 294.10 and 294.11, code first the underlying disease associated with the dementia, such as Alzheimer’s disease or Huntington’s disease.

Within ICD-9-CM, look for several different types of dementia or cerebral degeneration because advances in the treatment and study of dementia have allowed for the expansion of dementia code classifications. Report separately any behavioral disturbance associated with these dementias is reported separately using the appropriate code (294.10-294.11).

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Related Synonyms Include:

Dementia
Dementia late onset w hallucinations
Dementia without behavioral disturbance
Hallucinations co-occurrent and due to late-onset dementia
Mild dementia
Senile dementia
Senile dementia w delusions
Senile dementia with delirium
Senile dementia with delusion
Senile dementia with depression
Senile dementia with paranoia
Senile dementia with psychosis
Severe dementia
Mixed dementia
Moderate dementia
Organic dementia
Presbyophrenia
Presbyophrenic psychosis
Presenile dementia
Presenile dementia with delirium
Presenile dementia with delusions
Presenile dementia with depression
Primary degenerative dementia

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Basic ICD-10 INFORMATION

World Health Organization (WHO) authorized the publication of the International Classification of DiseasesExternal 10th Revision (ICD-10), which was implemented for mortality coding and classification from death certificates in the U.S. in 1999. The U.S. developed a Clinical Modification (ICD-10-CM) for medical diagnoses based on WHO’s ICD-10.  This medical classification list is generated by the World Health Organization (WHO), and is used to help healthcare providers identify and code health conditions.

ICD-10 is required for use by physicians and healthcare providers under the Health Insurance Portability & Accountability Act (HIPAA) and will replace all ICD-9 code sets. There are nearly 5 times as many diagnosis codes in ICD-10-CM than in ICD-9-CM.ICD-10 has alphanumeric categories instead of numeric ones.