Part B Insider (Multispecialty) Coding Alert

Dementia is a broad diagnosis, and can come from a number of causes, including cardiovascular deterioration and alcoholism. Too often, patients are shoehorned into a diagnosis such as Alzheimer's disease without eliminating other possibilities, say experts.

A psychiatrist or psychologist can make the initial diagnosis of dementia, but other physicians, such as neurologists, may have to narrow the diagnosis down further through a series of tests and evaluations. But unlike psychiatrists, who can bill a consult code or CPT 90801 (psychiatric diagnostic interview examination), other types of physicians are stuck billing an evaluation and management code.

"Evaluating dementia once it has been diagnosed is a different problem," says consultant Quinten Buechner with ProActive Consultants in Cumberland, WI. The physician must identify "the disease process that is resulting in the diagnosis of what appears to be dementia... You might use some altered mental status diagnostic codes" and then attempt to narrow the focus.

Most of the time, dementia will be a new problem with a higher workup and exam, and a lot of treatment options to consider, notes George Alex, managing partner with Iatro in Baltimore. So it's easy to justify a high level of medical decision making. But performing a history and physical with a demented patient may be more challenging.

Since many factors can contribute to the underlying dementia, it's important to obtain a thorough workup in terms of both history and physical exam, notes Alex.

It's important to remember that history can come from other sources as well as directly from the patient, says Alex. You can obtain history information from the patient's care-givers or family members. If the patient has no family members who can fill in the blanks, you may be able to claim an exception to history requirements that covers unconscious patients or people who are unable to answer questions. But there has to be documentation of an attempt to obtain information.

With a combative patient, it may be difficult to do a proper physical exam. It may be necessary to use mild sedation or restraints, or wait for a calmer moment with the patient, says Alex.