Neurology & Pain Management Coding Alert

Question: Notes indicate that the provider performed an office evaluation and management (E/M) service for a vascular dementia patient. The visit lasted 17 minutes and included straightforward medical decision making (MDM). Specifically, notes read “vasc dementia wo behavior dist.” How should I code this encounter?

Idaho Subscriber

Answer: You might want to check with the provider, but the shorthand looks like it represents vascular dementia without behavioral disturbance. You should report code F01.50 (Vascular dementia without behavioral disturbance) for vascular dementia without behavioral disturbance.

As for the E/M, your code choice will depend on patient status. For a new patient, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.). If this is an established patient, opt for 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.).

Don’t forget: When reporting a code from category F01.5- (Vascular dementia), you should code first the underlying physiological condition or sequelae of cerebrovascular disease, per the ICD-10-CM manual. For example, if the patient has vascular dementia without behavioral disturbance associated with cerebral atherosclerosis, you should report I67.2 (Cerebral atherosclerosis), F01.50 on your claim.