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January 14, 2013

Coding for Cognitive Disorders
For The Record
Vol. 25 No. 1 P. 26

Cognition is the process of awareness or thought and includes memory, language, attention, perception, and reasoning. A patient with a cognitive disorder has difficulty with one or more types of mental tasks. Cognitive disorders are brain disorders that typically occur in patients after middle age.

Common cognitive disorders include the following diagnoses:

• attention-deficit disorder (314.00), with hyperactivity (314.01);

• autism (299.00), autistic disorders in residual state (299.01);

• dementia (294.20), with behavioral disturbance (294.21);

• Down syndrome (758.0);

• dyscalculia (315.1);

• dyslexia (784.61);

• traumatic brain injury (854.01);

• traumatic head injury (959.01); and

• learning disabilities.

Dementia is the progressive impairment of brain function that affects a person’s ability to function at his or her usual level. The following are the major stages of dementia:

• mild cognitive impairment (memory problems);

• mild dementia (impaired memory and thinking skills);

• moderate dementia (severe memory impairment and difficulty in communication);

• severe dementia (severe problems with communication and frequent incontinence); and

• profound dementia (bedridden).

Dementia is a collection of disorders rather than a specific disease and can be attributed to various causes. The following are some common causes of irreversible dementia:

• Alzheimer’s disease (331.0 + 294.1x): The most common cause of dementia, Alzheimer’s disease is a progressive, degenerative brain disease characterized by the development of brain plaques consisting of a protein (beta amyloid). Treatment currently is directed toward symptom management and slowing disease progression by using cholinesterase inhibitors, including donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and memantine (Namenda). Research is focused on a preventive vaccine plus many new treatments.

Alzheimer’s disease may be classified as early or late onset. Early onset Alzheimer’s disease typically is defined as occurring prior to the age of 65, but the specificity must be documented by the physician and not determined based on the patient’s age.

• Multi-infarct dementia (290.4x + 437.0): Also called vascular dementia, multi-infarct dementia is caused by strokes that stop 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.

• Parkinson’s disease (331.82 + 294.1x): This is a progressive neurologic disorder in which dopamine-producing brain cells are lost. There are four primary symptoms of Parkinson’s: tremor in the extremities, face, and jaw; rigidity of the trunk and limbs; bradykinesia (slowness of movement); and impaired balance and coordination. As the disease progresses, it frequently is accompanied by depression; problems with chewing, swallowing, and speaking; problems with urination and constipation; sleep disturbances; and skin changes.

Treatment is symptomatic in nature. Medications to treat Parkinson’s include carbidopa/levodopa (Sinemet, Stalevo), dopamine agonists (Mirapex, Neupro, Parlodel, Requip), anticholinergics (Artane, Cogentin), monoamine oxidase-B inhibitors (Azilect, Eldepryl, Carbex, Zelapar), and catechol-O-methyl transferase inhibitors (Comtan, Tasmar).

As the disease and its symptoms progress, a surgical procedure may be performed to insert a deep brain stimulator. There is abnormal firing of movement circuits in the brain caused by the decrease in dopamine-producing cells, which results in the four classic symptoms. The deep brain stimulator firings are thought to disrupt the abnormal circuits.

• Dementia with Lewy bodies (331.82 + 294.1x): This condition causes protein deposits (Lewy bodies) in neurons. A unique symptom for this condition is visual hallucinations.
• Frontotemporal dementia (331.19 + 294.1x): The main symptom of this condition is changes in personality or behavior, including displays of inappropriate social behavior.

• Pick’s disease (331.11 + 294.1x)

• Huntington’s disease (333.4 + 294.1x), a rare, hereditary condition

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

• Binswanger’s disease (290.12), a type of vascular dementia

• Creutzfeldt-Jakob disease (046.19 + 294.1x): This is a progressive degenerative brain disorder that ultimately leads to dementia. Symptoms are similar to those of Alzheimer’s or other types of dementia, but the disease progression is more rapid. It is an extremely rare disease with only one in 100 million individuals being diagnosed each year. Treatment is directed toward symptom management and comfort.

In the late 1990s, a variant of the disease attributed to infected cattle, broke out in Great Britain (mad cow disease). However, the classic form is not related to ingestion of meat products.

• Multiple sclerosis (340 + 294.1x)

• HIV disease (042 + 294.1x)

• Neurosyphilis (category 094 + 294.1x)

Code 294.1 requires a fifth-digit subclassification to identify whether the dementia was present with or without behavioral disturbances, such as aggressive, combative, or violent behavior.

The physician must link the patient’s type of behavior to the dementia. Query the physician for correlation if a patient with dementia demonstrates one of the behaviors listed above but this information is not documented by a physician or linked to the dementia. The physician must document the behavior (as opposed to a nurse or other nonphysician clinician) before the dementia with behavior disturbance (294.11) can be coded.

Wandering used to be considered a behavioral disturbance. However, because of recent changes in coding directives, it has been deleted. In addition, a coding note has been added that states, “Use additional code, where applicable to identify wandering in conditions classified elsewhere (V40.31).”

Coding and sequencing for cognitive disorders are dependent on 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, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.


Coding for Dementia in ICD-10-CM
Several of the dementia categories are classified to the code range F01 to F09 in ICD-10-CM. Common to most of these categories is the code first note, which states to “code first the underlying physiological condition.”

Physicians should be encouraged to document a cause-and-effect relationship between the condition and the underlying cause. For example, physician documentation of “vascular dementia due to stroke six months ago” is more clear compared with “vascular dementia and a history of stroke” as final diagnoses without indicating cause and effect.

In ICD-10-CM, presenile and senile dementia are classified to the unspecified dementia category (F03).

ICD-10-CM maintains the ability to capture behavior disturbance in dementia as follows:

• F01.51, Vascular dementia with behavioral disturbance;

• F02.81, Dementia in other diseases classified elsewhere with behavior disturbance; and

• F03.91, Unspecified dementia with behavioral disturbance.

The behavioral disturbances are similar to ICD-9-CM and include aggressive, combative, and violent behaviors. As in ICD-9-CM, the physician must document the behavior and establish a cause-and-effect relationship between the behavior and the dementia.

— AH