Neurosurgery Coding Alert

Question: A 75-year-old established patient is experiencing reduced memory and functioning abilities. The patient was treated for a 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 the patient 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. Based on the observation of signs and symptoms, interpre­tation of the mental status examination and other neuropsy­chological tests along with lab studies and imaging studies, the physician confirms a diagnosis of vascular dementia. Should we report F01.50 or F01.51 for this condition?

Maine Subscriber

Answer: You should report F01.51 (Vascular dementia with behavioral disturbance) for this condition. Code F01.51 is the correct choice because the patient suffers from vascular dementia with aggressive, combative, or violent behavior.

On the other hand, if the physician had diagnosed the patient with vascular dementia without behavioral disturbance, then you would report F01.50 (Vascular dementia without behavioral disturbance).