by Wyn Staheli, Director of Content - innoviHealth
Mar 14th, 2023
Dementia is a neurocognitive disorder characterized by a meaningful decline in cognition and daily functioning. As of October 1, 2022, there were some significant changes in regards to reporting this condition, so it is important for healthcare professionals to be aware of those changes to ensure that there is proper documentation supporting the ICD-10-CM diagnosis code reported.
Within the ICD-10-CM code structure, dementia will most commonly be reported a code from the following three categories:
F01- “Vascular dementia”
F02- “Dementia in other diseases classified elsewhere”
F03- “Unspecified dementia”
Code selection is based on the severity (e.g., mild, moderate) as well as any associated behavioral and psychological symptoms of dementia (BPSD), non-cognitive behavioral changes (NCBC), or neuropsychiatric symptoms (NPS).
Note: There are other codes for dementia caused by substances such as F18.27 “Inhalant dependence with inhalant-induced dementia.” These diagnoses are not covered in this article. They can be found via a FindACode.com search. A substance use disorder coding table is included in the Behavioral Health Reimbursement Guide (available in the Find-A-Code online store).
Dementia Severity Classifications
It is essential to clearly document the severity of the dementia as one of the following generally accepted levels:
- Mild: Clearly evident functional impact on daily life, affecting mainly instrumental activities (things you do every day to take care of yourself and your home). In other words, the patient is no longer fully independent and/or requires occasional assistance with daily life activities.
- Moderate: Extensive functional impact on daily life with impairment in basic activities. No longer independent and requires frequent assistance with daily life activities.
- Severe: Clinical interview may not be possible. Complete dependency due to severe functional impact on daily life with impairment in basic activities, including basic self-care.
Even though there is a subcategory for unspecified dementia codes; for reimbursement purposes, it is always best to avoid using unspecified codes in order to improve communication with third-party payers.
Behavioral and Psychological Symptoms of Dementia
Prior to October 1, 2022, it was only necessary to report that there were behavioral disturbances. However, this has been changed and is now broken down into the following different types:
- Without behavioral / psychotic / mood / disturbance and anxiety
- With anxiety
- With agitation: Includes the following:
- Aggression (physical, verbal) such as profanity, shouting, threatening, anger, combativeness, or violence
- Violent behavior
- Aberrant motor behavior, (e.g., rocking, pacing, restlessness, exit-seeking)
- Verbal or physical behaviors such as profanity, shouting, threatening, anger, aggression,combativeness, or violence
- With mood disturbance including depression, apathy, anhedonia (lack of pleasure), and euphoria (great happiness).
- With other behavioral disturbance: Includes the following:
- Sleep disturbance
- Social disinhibition, (eg, intrusiveness)
- Sexual disinhibition
- With psychotic disturbance including hallucinations, paranoia, suspiciousness, and delusional state
Why Dementia Reporting Changed
The National Minority Quality Forum requested the coding changes because the previous codes for dementia did not identify either the stage of severity or the presence of specific behavioral and psychological symptoms of dementia (BPSD). These are necessary because they are directly related to patient management and treatment options. They stated that this granularity was needed “[p]articularly because dementia is progressive, there is a great need for the longitudinal clinical data to capture the stage of severity and the key associated disorders over time to move research and clinical studies forward.”
Note: In case you missed it, there was also a new subcategory (F06.7-) created for “Mild neurocognitive disorder due to known physiological condition”.
Insurance Coverage of Dementia
Insurance payers typically cover testing which is performed to detect neurological disorders (including dementia). The following information from one Medicare contractor provides some guidance for codes 96132, and 96133 (emphasis added):
The content of neuropsychological testing procedures differs from that of psychological testing in that neuropsychological testing consists primarily of individually administered ability tests that comprehensively sample cognitive and performance domains that are known to be sensitive to the functional integrity of the brain (e.g., abstraction, memory and learning, attention, language, problem solving, sensorimotor functions, constructional praxis, etc.). These procedures are objective and quantitative in nature and require the patient to directly demonstrate his/her level of competence in a particular cognitive domain. Neuropsychological testing does not rely on self-report questionnaires such as the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), rating scales such as the Hamilton Depression Rating Scale, or projective techniques such as the Rorschach or Thematic Apperception Test (TAT) when questions of how brain damage or degenerative disease processes (e.g. right hemisphere CVA) may be affecting emotional expression or how significant emotional distress or mood impairment might be affecting cognitive function (e.g. question of presence of "pseudodementia") arise.
— Psychiatry and Psychology Services (L33632)
The following information from Medicare provides some guidance in relation to coverage of psychotherapy services in relation to dementia:
Patients with dementia represent a very vulnerable population in which co-morbid psychiatric conditions are common. For such a patient to benefit:
Services are not covered when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective.
— Outpatient Psychiatry & Psychology Services (L31887)
As you can see, using the new more specific codes helps to establish medical necessity as outlined in payer policies. For example, a claim using a diagnosis of “Moderate” level of dementia would not meet this payer’s requirements.
The Behavioral Health Reimbursement Guide for 2023 includes a helpful dementia coding table along with procedure codes and other important reimbursement information.
About Wyn Staheli, Director of Content - innoviHealth
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.