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Home Health ICD-9/ICD-10 Alert

Coding 101:

Zero In On Etiology, Behavior Notes for Accurate Dementia Coding

Published on Wed Mar 14, 2012

Mind your sequencing with 294.1x.

A dementia diagnosis can impact the care you provide, as well as the case mix points you earn. Make certain you're coding this condition accurately or risk leaving reimbursement on the table.

Look to 294.2x Codes for Dementia without Details

When the physician diagnoses a patient with dementia and you can't gather any additional details about the cause, you'll look to the 294.2x (Dementia, unspecified) codes, says Jan McLain, RN, BS, LNC, HCS-D, COS-C, with Adventist Health System Home Care in Port Charlotte, Fla.

Whenever the patient has dementia without documentation of a specific cause or the diagnosis "Dementia, NOS," and the dementia impacts the home health plan of care, you should list a 294.2x code, says Judy Adams, RN, BSN, HCS-D, COS-C with Adams Home Care Consulting in Chapel Hill, N.C.

"Dementia is definitely a diagnosis that will impact the plan of care in nearly all situations," Adams says. Plus, it's a case mix diagnosis that offers one case mix point in equation 1 and three case mix points in equations 2 and 4 under the 2012 home health PPS.

If the documentation doesn't identify the etiology of the dementia but does document behavior disorders such as aggressive, combative, or violent behavior, then you'll list 294.21 (Dementia, unspecified, with behavioral disturbance), says McLain. Without behavior disturbance, list 294.20 (Dementia, unspecified, without behavioral disturbance).

New codes: The 294.2x codes were added with the 2012 ICD-9 updates along with another related code, notes McLain. New V code V40.31 (Wandering in diseases classified elsewhere) indicates the patient has documented behavior of wandering, she says. "Wandering is not considered to be inherent in dementia, but is a specific behavior that indicates a need for special safety precautions and should definitely be coded when documented."

Be sure to pair V40.31 with the fifth digit for 'with behaviors' regardless of whether you're using the 294.1x or 294.2x codes, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Don't miss: You must have physician documentation when coding any dementia or mental disorder, McLain says.

Coding example: Your new patient was admitted to home health for aftercare following a joint replacement. She also has diagnoses of dementia, hypertension and diabetes. List the following codes for this patient, says Adams:
  • M1020a: V54.81 (Aftercare following joint replacement);
  • M1022b: 294.20;
  • M1022c: 401.9 (Essential hypertension; unspecified);
  • M1022d: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled); and
  • M1022e: V43.65 (Organ or tissue replaced by other means; joint; knee).

Tip: More than likely, your coding manual does not indicate that new codes 294.20 and 294.21 are case mix, Selman-Holman says. The old code for dementia unspecified (294.8) is case mix, but when the inclusion note 'dementia NOS' was removed from that code and moved to the new codes, CMS failed to make the new codes case mix.

"It took several emails working with Mary St Pierre of NAHC and CMS, but persistence did prevail and CMS added the two new codes to the case mix list with the PPS changes effective January 1, 2012. The case mix status will be retroactive to October 1, 2011," Selman-Holman adds.

Takeaway point: Turn to the 294.2x codes in your coding manual and add some dollar signs to help remember these additional case mix codes.

Target 294.1x for Dementia as Manifestation

When dementia is associated with an underlying disease process, you have an etiology/manifestation coding situation, Adams says. In this scenario, code for the underlying disease or etiology first, followed by either 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance) or 294.11 (Dementia in conditions classified elsewhere with behavioral disturbance).

When the physician documentation indicates an associated condition, be sure to carefully review the wording, McLain says. If the dementia is associated with a neurological condition such as Alzheimer's (331.0), epilepsy (345.0-345.9), multiple sclerosis (340), or any of the other physical conditions listed in the "code first" note under 294.1 (Dementia in conditions classified elsewhere), list the code for the underlying disease process first, followed by 294.10 or 294.11. Then list V40.31 if there is documentation of wandering, she says.

For example: Code for Parkinson's disease with dementia but without behavioral problems with 332.0 (Parkinsons's) followed by 294.10, Selman-Holman says. While dementia associated with Huntington's chorea with behavioral issues would be coded with Huntington's chorea (333.4) followed by 294.11. Remember to add the code V40.31 (Wandering in diseases classified elsewhere) if that problem is identified.

Rely on 331.83 for Mild Cognitive Impairment

When the medical record states that a patient has mild cognitive impairment, rather than dementia, list 331.83 (Mild cognitive impairment, so stated), Adams says.

A patient with mild cognitive impairment displays evidence of impairment of his cognitive status without a documented underlying etiology or symptoms that warrant additional resources or techniques, McLain says. This code is used only when the physician diagnoses mild cognitive impairment without any other definitive diagnosis, she says.

Caution: There is a long list of excluded terms for 331.83 in the Tabular List of your ICD-9 manual, Adams says. These include altered mental status, cognitive impairment due to head injury, and mild memory disturbance. Make sure to verify the code in the Tabular List and read the Excludes list before reporting 331.83.

Coding example: Your patient was admitted to home health from the doctor's office for assessment and observation due to elevated blood sugars in a known diabetic. The physician states that the patient has noninsulin-dependent diabetes mellitus and is on oral medication. The physician says the patient claims to be compliant with diet and oral medications, but before he adds insulin to the medication regimen, he wants a baseline as to whether she is compliant or able to manage her insulin administration. The physician also notes that the patient has a mild cognitive impairment.

Code for this patient with the following codes, says McLain:
  • M1020a: 250.00 and
  • M1022b: 331.83.

Note: See Test Yourself on page 38 to put your coding skills to the test with our dementia coding scenarios.

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