Neurology & Pain Management Coding Alert

Question: Encounter notes indicate a patient is diagnosed with severe vascular dementia. The provider notes that the patient exhibits “rocking, profanity, and is obsessed with knowing where the exits are.” Is there an ICD-10-CM code that represents this specific type of dementia?

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Answer: Yes, there is a specific code for this patient: F01.C11 (Vascular dementia, severe, with agitation). There are very involved explanations for each type of severe vascular dementia beneath the code descriptors. Each of them reveals more about the condition specified in the dementia diagnosis. For F01.C11 patients, signs of agitation include restlessness, rocking, pacing, exit-seeking, profanity, shouting, threatening, anger, aggression, combativeness, and violence.

If the patient is confirmed to have severe vascular dementia without behavioral disturbance, you’d have chosen F01.C0 (Vascular dementia, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety). When the vascular dementia is accompanied by a disturbance, however, you’ll need to choose different ICD-10-CM codes.

Check out this quick guide to each type of vascular dementia with disturbance. For more involved disturbance explanations, check beneath the descriptors of each individual code:

• If the patient/patient’s guardian reports sleep disturbance, social disinhibition, or sexual disinhibition, the best diagnosis code is F01.C18 (Vascular dementia, severe, with other behavioral disturbance).
• If the patient/patient’s guardian reports hallucinations, paranoia, suspiciousness, or delusional state, report F01.C2 (Vascular dementia, severe, with psychotic disturbance).
• If the patient/patient’s guardian reports depression, apathy, or anhedonia (inability to experience joy or pleasure), report F01.C3 (Vascular dementia, severe, with mood disturbance).
• If the patient/patient’s guardian reports anxiety, report F01.C4 (Vascular dementia, severe, with anxiety).

Chris Boucher, MS, CPC, Senior Development Editor, AAPC