CDI Tips: Dementia

Dementia: Will we need more queries?

CDI Tip Dementia

The short answer is yes! We need documentation of none, other, or a specified type of mood disorder. 

But here is the long answer:

“Dementia The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate, or severe). Selection of the appropriate severity level requires the provider’s clinical judgment, and codes should be assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting) unless otherwise instructed by the classification. If the documentation does not provide information about the severity of dementia, assign the appropriate code for unspecified severity. If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.” (2023 ICD-10-CM official guidelines, page 43.)

To accurately assign dementia, it is necessary for the provider to document the severity of dementia as mild, moderate, or severe.

  • Mild is coded with the fourth character A
  • Moderate is coded with the fourth character B
  • Severe is coded with the fourth character C

For example, Vascular dementia, Moderate is coded to F01.B-. There is a code for unspecified severity F03.9, but as CDI specialists, if we are going to query for the type of behavioral disturbance, we could ask for severity as well. Unspecified severity can be coded if the provider really does not know. The severity of dementia does not determine if the code is a CC.

However, there is no code for unspecified mood disturbance, only for other and without. The dementia code without behavioral disturbance is not a CC. Specified disturbances such as psychotic disturbance, agitation, mood disturbance, or anxiety are CCs. The tabular section of the ICD-10-CM code book found at www.CMS.gov/Medicare/coding/ICD10 gives examples of what is included in these different behavioral disturbances.

Where do you find clinical indicators to support documentation of behavioral disturbances?

  • Previous encounters: Has the patient been seen previously with documentation of behavioral disturbances related to dementia? How were they described? Be sure to include the date and location of the information in your query!
  • Nursing documentation: Does nursing describe behaviors that could be included in your query to support the query regarding the specificity of behavioral disturbances?
  • Social services documentation: Is there documentation that indicates behavior has been a problem at home? Have family members indicated there are behavioral issues at home?
  • Consult notes: Has the patient been evaluated by psychiatry, neurology, or gerontology related to dementia?
  • Medications: Is the patient on medications that indicate there is a behavioral component of their dementia that is being treated?
  • Provider documentation: Does the doctor mention any signs and symptoms such as hallucinations, or “the patient is anxious”? Look for statements that could support a query for a specific behavioral disturbance.

Remember that complete and accurate documentation improves patient care across the continuum of care, and the clinical documentation specialist plays a key role in making this happen.