Primary Care Coding Alert

Hint: All associated behavioral problems come under one code choice.

Don’t be vexed about identifying associated behavioral problems when your clinician diagnoses vascular dementia, as your coding options have been simplified in ICD-10. You will no longer need to select a code depending on type of associated behavioral issues as you would do in ICD-9.

ICD-9: When your FP 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 absence of 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.

Don’t Forget These Basics

Your FP 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 FP 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 FP notes in the documentation of a patient diagnosed with vascular dementia. Some of the common signs and symptoms that your FP 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 FP 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 FP at later dates. If the patient’s behavioral problems, such as depression, are not controlled by medication, your FP might recommend electroconvulsive therapy.

Coding example: Your FP assesses a 75-year-old established patient with reduced memory and functioning abilities. The patient is accompanied by his daughter who says that he had a history of 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 daughter 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 FP 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 FP 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.