Code for Diagnostic Accuracy: Dementia, Alzheimer’s, and Senility
By Trina Cuppett, CPC, CPC-H, CPC-I
Factor in the assessment, behavioral disturbances, and cause.
Dementia, Alzheimer’s, and senility are often confused and mistakenly grouped together as if these conditions were synonymous. By differentiating these terms, you can be more confident assigning diagnosis codes to accurately reflect clinical documentation.
Dementia is a broad term describing a set of symptoms, not a disease itself. Typical signs of dementia are a loss of cognitive abilities, behavioral and emotional changes, the loss of ability to perform activities of daily learning (ADLs), and a loss of instrumental activities of daily living (IADLs). Generalized symptoms of dementia may be seen in patients with specific conditions such as Alzheimer’s or vascular dementia.
Dementia usually is preceded by mild cognitive impairment (MCI), which describes the normal forgetfulness that occurs with aging, depression, or severe stress. Not everyone with mild cognitive impairment will progress to dementia. At this point, patients may still be living independently, but require some adjustments with their hygiene and social activities may be impaired.
During the second stage, early dementia, the patient cannot continue any employment, and independent living is hazardous. The individual requires supervision to prevent accidents inside or outside the home. Retention of information read, seen, or heard may be diminished.
In the third stage of dementia, the patient requires constant supervision. Daily living activities become severely impaired and the patient needs assistance to perform even small tasks. Walking and sitting become difficult; there is diminished control of psychomotor functions; and there may be urinary incontinence. Patients will need assistance with feeding, toileting, and bathing. Anxiety, agitation, delusional behavior, or obsessive tendencies not present before may be present during this stage.
Diagnosing dementia normally involves a mini-mental state examination (MMSE), which consists of questions to gauge a person’s mental abilities, memory abilities, and language. Note that a person’s level of education and health problems, such as a disability or an inability to speak or read English fluently, will affect that patient’s ability to be diagnosed using the MMSE. In any of these instances, another method should be used to aide in the diagnosis of dementia.
MMSE scores are used to help the physician decide what types of medications can be used for the dementia, depending on its severity. Table A is an example of how the MMSE is used to decide Alzheimer’s medication treatment, according to the severity score.
|MMSE Score and Treatment of Alzheimer’s Disease|
|Mild-to-moderate Alzheimer’s disease||Score 10-26||(Aricept), (Exelon), or (Reminyl)|
|Severe||Score less than 10||(Ebixa)|
Source: Information based on National Institute for Health and Clinical Excellence (NICE) guidance as of 2011.
There is no specific CPT® or HCPCS Level II code to report an MMSE. Rather, the 1997 Documentation Guidelines for Evaluation and Management Services includes a, “brief assessment of mental status including: orientation to time, place and person; recent and remote memory; mood and affect (e.g., depression, anxiety, agitation)” as part of the exam elements for a general multi-system exam.
Avoid this: Coders often mistakenly apply 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report for the MMSE. The MMSE usually takes less than 10 minutes to complete; whereas, the neurobehavioral status exam, properly reported using 96116, is more extensive and rated “per hour” of the psychologist’s or physician’s time.
Alzheimer’s is a “particular cause” of dementia, as well as the leading cause of progressive dementia. Individuals with Alzheimer’s disease live, on average, for seven to nine years after being diagnosed; however, an Alzheimer’s patient who is otherwise healthy may live 20 years or longer. Alzheimer’s affects approximately five million people in the United States. This number is expected to triple by the year 2050 as medical advancements and new technologies enable people to live longer.
- Early onset Alzheimer’s usually occurs from age 40-60, and tends to occur in individuals with a genetic predisposition to the illness. This would be coded 331.0 Alzheimer’s disease, and either 294.11 Dementia in conditions classified elsewhere with behavioral disturbance or 294.10 Dementia in conditions classified elsewhere without behavioral disturbance. Behavioral disturbances include aggressive, combative, or violent behavior.
- Late onset Alzheimer’s usually occurs in individuals age 60-80. It is coded the same as early onset Alzheimer’s. Remember to use 294.11 to specify “with behavioral disturbances” or 294.10 to specify “without behavioral disturbance,” in addition to 331.0.
Diagnosing Alzheimer’s usually involves taking a family and patient (personal) history; conducting a physical, neurological, and psychiatric exam; blood work; and brain imaging. Alzheimer’s can be definitively diagnosed only after death. A beta-amyloid protein causing plaques in the brain resulting in Alzheimer’s can be directly observed only during autopsy of the brain.
Senile dementia is considered an outdated term, according to the Alzheimer’s Society. Conditions specifically documented as “senile” or “pre-senile” dementia without further detail may be classified to codes 290.0-290.3.
If a patient has documented symptoms of dementia, but the underlying cause is undocumented, report 294.20 Dementia, unspecified, without behavioral disturbance or 294.21 Dementia, unspecified, with behavioral disturbance. Ideally, if a patient has dementia, the coder should query the physician to determine the type (the coder may not infer information not explicitly stated in the patient record).
Other, Specified Causes of Dementia
Dementia may result from other specific conditions, such as:
Vascular dementia: Vascular dementia is the second most prominent cause of progressive dementia (after Alzheimer’s). It usually occurs after a stroke, heart attack, or in patients with high blood pressure (hence the term: vascular). Vascular dementia and Alzheimer’s may coexist in some patients. Codes 290.40-290.43 are used to code the specific type of vascular dementia. For example, if a patient has Vascular dementia, with delirium, 290.41 would apply. You could also apply 437.0, for instance, to identify Cerebral atherosclerosis.
Dementia with Lewy bodies: Lewy bodies consist of abnormal clumps of protein found in the brain (similar to those of Alzheimer’s patients). A very distinct aspect of Lewy body dementia is that patients will fluctuate between periods of lucidity and confusion. Code 331.82 Dementia with Lewy bodies applies for dementia with Parkinsonism, Lewy body dementia, or Lewy body disease.
Frontotemporal dementia: Also known as Pick’s disease, Arnold Pick’s disease, or semantic dementia, this dementia type usually occurs in patients aged 40-60 years. It is a rare form of dementia that affects only certain areas of the brain. Abnormal substances known as Pick bodies, which contain tau (an abnormal protein), are found inside the nerve cells of the brain.
Report 294.11 or 294.10 depending on whether the dementia is with or without behavioral disturbances, respectively. You must also code the underlying physical condition: If a patient is specifically diagnosed with Pick’s disease, report 331.11; and for other frontotemporal dementia, report 331.19.
Several other disorders—including Creutzfeldt-Jakob disease, dementia pugilistica, HIV-associated dementia, Huntington’s disease, and Parkinson’s disease—are linked to dementia, although the relationships are not entirely understood:
- Creutzfeldt-Jakob disease coding calls for 046.11 Variant Creutzfeldt-Jakob disease or 046.19 Other and unspecified Creutzfeldt-Jakob disease. Identify associated dementia using 294.11 (with behavioral disturbances) or 294.10 (without behavioral disturbances).
- Dementia pugilistica is a type of dementia caused by repeated trauma to the head. This type of dementia can plague boxers, football players, and other patients who have participated in athletics. To code dementia pugilistica, report first 310.2 Postconcussion syndrome. Report also either 294.11 or 294.10, as applicable.
- HIV-associated dementia coding calls for 042 Human immunodeficiency virus [HIV] disease along with 294.1x, as appropriate.
- Dementia associated with Huntington’s chorea would be coded as 333.4 Huntington’s chorea then 294.10.
- Dementia with Parkinson’s disease is classified as 331.82, with 294.1x as a secondary diagnosis.
Sometimes, dementia (or dementia-like symptoms) may be reversed by treating an underlying issue. For example:
- Alcohol abuse, which can also lead to dehydration and deficiency of vitamin B-1, can cause dementia-like symptoms that may be reversed with hydration and increased vitamin B-1 levels.
- Anoxia (hypoxia) occurs when the organ tissue is not receiving an adequate supply of oxygen. Reversal depends on how severe the deprivation.
- Brain tumors may cause dementia-like symptoms in rare cases. When the tumor is removed or treated, these symptoms may reverse.
- Endocrine disorders, such as hypoglycemia (low blood sugar), may cause dementia-like symptoms.
- Heart and lung problems deprive the brain of oxygen, which can cause dementia-like symptoms. Patients may need to have their oxygen levels monitored or use portable oxygen to ensure they receive an adequate supply.
- Infections and immune disorders, including brain infections such as meningitis or encephalitis, untreated syphilis, Lyme disease, leukemia, and multiple sclerosis can cause dementia.
- Metabolic conditions, such as a vitamin B-12 deficiency or hypothyroidism, can cause dementia-like symptoms, as may too much or too little calcium or sodium in the body.
In addition, dementia-like symptoms may be the result of a medication reaction, subdural hematomas, and exposure to chemicals (e.g., pesticides) or heavy metals (e.g., lead). The dementia-like symptoms may resolve with the underlying condition, or as exposure to the substance is ended.
When coding for dementias that may be reversed, code the actual disease being treated (e.g., hypothyroidism, 244.x), along with 294.2x.
Trina Cuppett, CPC, CPC-H, CPC-I, is president of United Coding & Medical Institute, LLC, in Hickory, N.C. She was an AAPC National Advisory Board member in 2009-2011.