Wiki Alzheimer's ICD-10 Help!

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valdez540

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MD states Alzheimer's in his H&P.

When coding ICD-10 it states use additional code to Identify: Dementia with or W/O disturbance or delirium. MD does not indicate any of these things. Do you code Alzheimer's unspecified G30.9 only? or do you assume W/O disturbance F02.80?

My issue is that I have always been told not to assume and I have not been able to find something stating the default would be w/o disturbance. Help!
 
All of he G30 codes need the additional code. This is just another example of the specificity of ICD-10 CM. the provide will need to document whether there is any behavioral disturbance. You cannot default this.
 
Thank you for your response! I just got coding guidance that the default would be w/o due to the alphabetical index having F02.80 in brackets. Would you agree? I agree with you that the MD should have to indicate! I have ALWAYS been told not to assume when coding.
 
There is nothing in the guidelines to support that you are able to default this. I feel it is too critical to the patient that we get this correct. I would have to see the note. But if in the note the provide indicates there are no behavioral issues then I am good with it.
 
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