Outpatient Facility Coding Alert

Remember to pay attention to associated conditions.

One of the most common challenges for coders face when reporting dementia is that the terms “dementia” and “Alzheimer’s” are used interchangeably, when actually their clinical parameters are different. Read on for vital information that will help you distinguish the difference every time.

Begin With the Basics of Dementia

Dementia is the loss of cognitive functioning, thinking, remembering, and reasoning and behavioral abilities to such an extent that it interferes with a person’s daily life and activities. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person’s functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living.

The causes of dementia can vary, depending on the types of brain changes that may be taking place. It is common for people to have mixed dementia—a combination of two or more disorders, at least one of which is dementia (such as Alzheimer’s disease and vascular dementia).

Therefore, “dementia” is a global term for a set of symptoms that can include impaired thinking and memory often associated with the cognitive decline of aging. Patients with dementia may also show problems with motor skills, object recognition, and the ability to plan, organize, and abstract.

Run Through the Reasons

Alzheimer’s is the leading cause of dementia, associated with as many as 50 to 70 percent of cases, according to the Centers for Disease Control and Prevention.

Other conditions that may cause memory loss or dementia include:

• Medication side effects (T88.7)
• Chronic alcoholism (F10.20)
• Tumors or infections in the brain (D33.2)
• Blood clots in the brain (D75.9)
• Vitamin B12 deficiency (D51)
• Some thyroid, kidney, or liver disorders (N25-N29)
• Stroke (I63.9 )
• Parkinson’s disease (G20)
• Huntington’s disease (G10)
• Creutzfeldt-Jakob disease (A81.00)
• Sleep disorder (G47).

Code Correctly With ICD-10

Physicians use many screening tests to determine the cause of dementia, including blood tests, mental status evaluations, and brain scans. Once your physician pinpoints the cause and diagnoses a specific type, you can code the patient’s condition more accurately. 

Codes for dementia are located in categories F01-F03 in ICD-10-CM. The categories available are:

• F01 – Vascular dementia
• F02 – Dementia in other diseases
• F03 – Unspecified dementia.

In fact, each category for dementia requires providers to specify whether the patient has behavioral disturbances. For example, you have two code choices for vascular dementia: without behavioral disturbance (F01.50) and with behavioral disturbance (F01.51). The ICD-10-CM Manual includes synonymous terms for behavioral disturbances such as aggressive, combative, or violent behavior.

Code the Underlying Disease First

Don’t forget to code the underlying physiological condition or sequalae of cerebrovascular disease for these diagnoses. When you are reporting F01.51, for example, coders are instructed to use an additional code, if applicable, to identify wandering in vascular dementia (Z91.83).

Providers may need to document additional information about the underlying physiological condition in order for coders to choose the most specific code. For example, when reporting Alzheimer’s, ICD-10 includes the following options:

• G30.0 – Alzheimer’s disease with early onset
• G30.1 – Alzheimer’s disease with late onset
• G30.8 –  Other Alzheimer’s disease
• G30.9 – Alzheimer’s disease, unspecified.

Snapshot scenario: An elderly woman was diagnosed with vascular dementia after a stroke. She has experienced progressive short memory loss issues for the past few months. She has lost her interest in daily life, has balance problems, and forgets to take her medications. The diagnosis codes for her situation would be:

• I69.31 – Cognitive deficits following cerebral infarction
• F01.50 – Vascular dementia without behavioral disturbance.

Providers also need to document any associated delirium or dementia, as the ICD-10-CM Manual instructs coders to use an additional code to identify these conditions when applicable.

Final note: Because dementia, Alzheimer’s, and other allied cognitive disorders are often confused and mistakenly grouped together or used synonymously, correct clinical documentation is imperative. If the symptoms and associated diagnosis are clearly reflected in the physician’s note, assigning the applicable diagnosis code becomes easier and safer.

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