Neurosurgery Coding Alert

You needn't describe the associated behavioral problems as you did in ICD-9.

ICD-10 simplifies your options for vascular dementia. Though you will look for any associated behavioral problems that your physician documents, you needn't dig deep into describing the behavioral issues in specific.

ICD-9: When your physician arrives at a diagnosis of vascular dementia, you use 290.4x (Vascular dementia). Depending on the presence or absence of behavioral problems such as delirium, delusions, or depression, you

use a 5th digit expansion as follows:

• 290.40 -- Vascular dementia, uncomplicated
• 290.41 -- Vascular dementia, with delirium
• 290.42 -- Vascular dementia, with delusions
• 290.43 -- Vascular dementia, with depressed mood

ICD-10: When reporting a diagnosis of vascular dementia, 290.4 in ICD-9 crosswalks to F01.5 (Vascular dementia). Like in ICD-9, F01.5 also takes up a 5th digit expansion, depending on the presence or absenceof behavioral disturbance. However, in ICD-10, you will only have two codes depending on the presence or absence of behavioral disturbance. This simplifies your reporting of a diagnosis of vascular dementia, as you will not have to worry about identifying the type of behavioral disturbance that co-exists with the dementia.

So, based on the presence or absence of behavioral problems with vascular dementia, you will report the diagnosis with the following two codes:

• F01.50 -- Vascular dementia without behavioral disturbance
• F01.51 -- Vascular dementia with behavioral disturbance

Note: You will use F01.51 when your clinician diagnoses vascular dementia with aggressive, combative, or violent behavior or if any other behavioral problems co-exist with the signs and symptoms of vascular dementia.

"Like ICD-9, ICD-10 directs you to code first the underlying physiological condition or sequelae of cerebrovascular disease associated with the dementia," notes Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians. (ICD-9 actually says, "Code first the associated neurological condition.")

"Thus, if the vascular dementia is associated with cerebral atherosclerosis, in ICD-9 you would report 437.0 (Cerebral atherosclerosis) first, followed by 290.4x; in ICD-10, it would be I67.2 (Cerebral atherosclerosis) followed by F01.5_," Moore advises.

"This is similar to other conditions which are a consequence of another primary diagnosis. One should report the pathophysiological entity that causes the subsequent condition first," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Don't Forget These Basics

Your physician will arrive at a diagnosis of vascular dementia based on a complete history and an evaluation of the person's signs and symptoms. This service would include a complete mental status examination, a complete psychiatric and medical history of the patient and family, a review of systems, and ordering and interpreting neuropsychological and other diagnostic tests. Your physician will also assess the patient for behavioral problems that co-exist with dementia.

You might encounter a wide range of signs and symptoms that your physician notes in the documentation of a patient diagnosed with vascular dementia. Some of the common signs and symptoms that your physician might record include paranoia, hallucinations, delusions, confusion, mood swings, reduced ability to perform day-to-day activities, memory loss, slurred speech, tremors, weakness in the extremities, and urinary incontinence.

Document tests: When your physician suspects a diagnosis of vascular dementia, he will perform many different tests and diagnostic assessments. He will perform diagnostic assessments such as a Folstein Mini Mental Status Examination and Geriatric Depression Scale (GDS) and perform neuropsychological tests along with assessments for behavioral problems.

In addition, he might order many laboratory tests such as CBC, ESR, blood sugar, liver and kidney function tests, thyroid function test, and tests for vitamin B-12 or folate to rule out other causes for dementia. He might also ask for an MRI or CT of the brain to confirm the diagnosis of vascular dementia. He might subject the patient to other tests such as echocardiography and holter monitoring to assess the patient for stroke.

The care planning will include medical management with anti-platelet medications to prevent further occurrence of strokes and antidepressant medication to help manage behavioral problems. The effects of these medications will be checked at regular intervals by your physician at later dates. If the patient's behavioral problems, such as depression, are not controlled by medication, your physician might recommend electroconvulsive therapy.

Coding example: Your physician assesses a 75-year-old established patient with reduced memory and functioning abilities who is reported to have been treated for head injury after a fall about a year and a half back. After some time following the fall, his memory and functioning abilities began to deteriorate, and his caretaker says that it has presently reached a level where he is not able to organize his day-to-day activities without help.

In addition, she complains that his speech has become slurred a bit, and he experiences many mood swings, such as being irritable, combative, and depressed. He also suffers from occasional incidents of fecal and urinal incontinence. The patient also has a history of hypertension and diabetes.

Your physician conducts a thorough examination of the patient and performs a Folstein mini mental status examination of the patient along with GDS. The scoring on the mini mental status examination is 22/30 and GDS is 4/15. He also performs a neuropsychological examination that helps identify verbal and cognitive deficits. Suspecting dementia, he orders blood tests that rule out dementia due to other conditions. He also orders a CT of the brain that shows infarcts in multiple regions.

Based on the observation of the signs and symptoms, interpretation of the mental status examination and other neuropsychological tests along with lab studies and imaging studies, your physician confirms a diagnosis of vascular dementia.

What to report: You report the session with an appropriate E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient...). You report the diagnosis with F01.51 using ICD-10 coding system or 290.43 if you're using ICD-9.