Psychiatry Coding & Reimbursement Alert

Question: When reporting a diagnosis of dementia, we are now being told that the diagnosis code, 294.11 will need an underlying condition such as Alzheimer’s or epilepsy. What if the patient does not have any other underlying conditions or if the patient has developed dementia due to old age? What codes should we use to report in such a case?

Illinois Subscriber

Answer: You are right that you will need to report an underlying cause when reporting a diagnosis of dementia from the ICD-9 code range, 294.1x (Dementia in conditions classified elsewhere). When there is an underlying cause to which the dementia is attributed, you will have to code first this underlying cause that has led to the dementia as the primary diagnosis (for instance, you will report Alzheimer’s with the ICD-9 code 331.0 as the primary diagnosis) and then report from 294.1x to report the dementia.

But, when your clinician diagnoses a patient with dementia and you can’t gather any additional details about the cause, you’ll look to the 294.2x (Dementia, unspecified) codes. If the documentation doesn’t identify the etiology of the dementia but does document behavior disorders such as aggressive, combative, or violent behavior, then you’ll list 294.21 (Dementia, unspecified, with behavioral disturbance). When there is no mention of behavioral disturbance in the documentation, report 294.20 (Dementia, unspecified, without behavioral disturbance). 

If the patient’s documentation mentions “wandering behavior” then you will have to report it additionally with the V code (V40.31, Wandering in diseases classified elsewhere). Wandering is not considered to be inherent in dementia, but is a specific behavior that indicates a need for special safety precautions. You should definitely code this when documented.

Alternative: You can also look at the 290 series of ICD-9 codes, especially when the diagnosis is dementia due to old age. For instance, code 290.1x covers presenile dementia, while codes 290.0, 290.2x, and 290.3 cover various instances of senile dementia. Vascular dementia is represented by 290.4x; if you use this code, you will also use an additional code to identify cerebral atherosclerosis (e.g. 437.0). Other symptoms such as depressive features, delusional features, or delirium will help distinguish which fifth digit you use with some of these codes (such as 290.1x) or otherwise distinguish codes in the 290 series (e.g., 290.2x, which covers senile dementia with delusional or depressive features, versus 290.3, which covers senile dementia with delirium).