Neurosurgery Coding Alert

Question: Our neurosurgeon saw a 75-year-old established patient with reduced memory and functioning abilities who was treated for head injury after a fall about a year and a half ago. His memory and functioning abilities began to deteriorate after he fell, and his caretaker reported that he is no longer able to organize his day-to-day activities without help. In addition, she said that his speech has become slurred, and he has 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. The neurosurgeon examined the patient and performed a Folstein mini mental status examination of the patient along with GDS. He also performed a neuropsychological examination to identify verbal and cognitive deficits. Suspecting dementia, he ordered blood tests to rule out dementia due to other conditions and a CT of the brain, which showed infarcts in multiple regions. The doctor then confirmed a diagnosis of vascular dementia. Which diagnosis codes should we report?

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Answer: You should report the diagnosis with F01.51 (Vascular dementia with behavioral disturbance), because the patient’s behavior includes disturbing symptoms, which in your case is his combative behavior. If the patient didn’t experience that symptom, you would instead report F01.50 (Vascular dementia without behavioral disturbance), which refers only to the vascular dementia and does not require a behavior disturbance diagnosis.