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September 6, 2004

Coding for Dementia
For the Record
Vol. 16 No. 18 Page 38

Dementia is a progressive impairment of brain function so severe that it affects a person’s ability to function at his or her usual level. Described as a chronic degenerative disease, it is often irreversible.

Stages of Dementia
The following are the major stages of dementia:
1. Mild cognitive impairment – memory problems

2. Mild dementia – impaired memory and thinking skills

3. Moderate dementia – severe memory impairment and difficulty communicating

4. Severe dementia – severe communication problems and frequent incontinence

5. Profound dementia – bedridden

At some point during the stages of dementia, it becomes apparent that the patient can no longer live alone.

Causes of Dementia
The following are some causes of irreversible dementia:

• Alzheimer’s disease (331.0 + 294.1x) — the most common cause of dementia

• Multi-infarct dementia (290.4x + 437.0) — caused by strokes that stop the blood flow to parts of the brain. The fifth-digit subclassification with code 290.4 identifies the presence of delirium, delusional features, or depressive features. This type of dementia may also be documented as vascular dementia.

• Parkinson’s disease (331.82 + 294.1x) — a movement disorder with bradykinesia, rigidity, and tremors

• Dementia with Lewy bodies (331.82 + 294.1x) — causes protein deposits (Lewy bodies) in neurons. A unique symptom for this condition is visual hallucinations.

• Frontotemporal dementia (331.19 + 294.1x) — main symptom is changes in personality or behavior. The patient may display inappropriate social behavior.

• Pick’s disease (331.11 + 294.1x)

• Huntington’s disease (333.4 + 294.1x) — rare, inherited disease

• Leukoencephalopathies (323.9 + 294.1x) — affects the deeper, or white matter, brain tissue

• Binswanger’s disease (290.12 + 294.1x) — a type of vascular dementia

• Creutzfeldt-Jakob disease (046.1 + 294.1x) — infectious protein particles called prions destroy brain tissue

• Multiple sclerosis (340 + 294.1x)

• HIV (042 + 294.1x)

• Neurosyphilis (094.9 + 294.1x)
Code 294.1 requires a fifth-digit subclassification to identify whether the dementia was with or without behavioral disturbances. Behavioral disturbances include the following:

• Aggressive behavior

• Combative behavior

• Violent behavior

• Wandering off

Dementia not further specified is assigned to ICD-9-CM code 294.8. Drug-induced dementia is classified to code 292.82.

Dementia can also be caused by some treatable conditions such as hypothyroidism, vitamin or folic acid deficiency, heavy-metal poisoning, some brain tumors, normal pressure hydrocephalus, chronic alcoholism, and some infections. When the underlying cause is treated, it is possible to reverse the effects of dementia.

Dementia is different than delirium, which is the short-term change in mental status because of a new or worsening illness.

Symptoms
The earliest and most noticeable symptom of dementia is progressive memory loss. Other symptoms include the following:

• impaired recognition;

• inability to concentrate;

• difficulty with finding words;

• difficulty with understanding words spoken to them;

• decrease in problem-solving skills and judgment capability;

• difficulty planning and carrying out tasks;

• changes in mood, personality, and behavior;

• depression, anxiety, and agitation;

• severe confusion;

• altered sleep patterns; and

• motor system impairment.

Diagnosis
The physician may be able to diagnose dementia based on medical history of symptoms and a neurological exam. However, an autopsy is the only way to confirm the diagnosis and the type of dementia.

Treatment
If the dementia cannot be reversed, the goal of treatment is to control the symptoms. The physician may prescribe one or more of the following medications:

• Cholinesterase inhibitors — improve mental function in early Alzheimer’s disease and dementia in Lewy bodies. May include donepezil (Aricept), rivastigmine (Exelon), or galantamine (Reminyl)

• Antidepressants, including selective serotonin reuptake inhibitors such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram oxalate (Lexapro)

• Antipsychotics such as risperidone (Risperdal) and olanzapine (Zyprexa) to treat anxiety, agitation, aggression, and sleep problems

Coding and sequencing for dementia are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, and Vicki Sippel, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information

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