The patient is an 87-year-old male with a documented history of dementia, who was admitted to the hospital with transient changes in his mental status following a medical procedure. He was transferred to a subacute rehab facility for further management of acute delirium and behavior problems. The transfer summary listed delirium secondary to dementia as the final diagnosis. What is the appropriate code assignment for delirium due to dementia? I am reluctant to use code 290.3, Senile dementia with delirium, since the provider does not specifically document senile dementia.
Query the provider regarding the type of dementia (e.g., senile dementia, pre-senile dementia, etc.) and code accordingly. If the provider confirms that the patient has senile dementia with delirium, assign only code 290.3, Senile dementia with delirium. If the cause of the delirium or the type of dementia is not known, assign code 294.8, Other persistent mental disorders due to conditions classified elsewhere, and code 293.0, Delirium due to conditions classified elsewhere.