Neurosurgery Coding Alert

Check the documentation for behavioral disturbance indications.

Since ICD-10-CM offers so many diagnosis codes to choose from, it can be difficult to know which ones you should report on your specific claims. Luckily, if you are reporting vascular dementia, you only have ICD-10-CM codes to consider. However, you should still check the medical documentation for certain details to make sure you report the correct code.

Read on to learn more.

First, Define Vascular Dementia for Clarity

Question 1: What is vascular dementia?

Answer 1: Vascular dementia is a form of dementia caused by the lack of blood supply to the patient’s brain, which leads to brain damage resulting in loss of memory and other cognitive disorders.

Pinpoint 2 Dx Codes for Vascular Dementia
Question 2: Which ICD-10-CM codes should I report for vascular dementia?

Answer 2: You can look to the following two codes for vascular dementia:

• F01.50 (Vascular dementia without behavioral disturbance)
• F01.51 (Vascular dementia with behavioral disturbance)

You will choose between the above two codes depending on the presence or absence of behavioral disturbance. You will report F01.50 for vascular dementia without behavioral disturbance. On the other hand, you should report F01.51 when your physician diagnoses vascular dementia with aggressive, combative, or violent behavior or if any other behavioral problems co-exist with the signs and symptoms of vascular dementia.

Coding rules: 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 would report I67.2 (Cerebral atherosclerosis), followed by F01.50 on your claim.

This is similar to other conditions that are a consequence of another primary diagnosis, says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. You should report the pathophysiological entity that causes the subsequent condition first.

Don’t Miss Included Conditions

Question 3: Do codes F01.50 and F01.51 include any other conditions?

Answer 3: Yes. Along with vascular dementia without behavioral disturbance, F01.50 also includes major neurocognitive disorder without behavioral disturbance.

Additionally, code F01.51 encompasses numerous included conditions besides vascular dementia with behavioral disturbance. These are as follows:

• Major neurocognitive disorder due to vascular disease, with behavioral disturbance
• Major neurocognitive disorder with aggressive behavior
• Major neurocognitive disorder with combative behavior
• Major neurocognitive disorder with violent behavior
• Vascular dementia with aggressive behavior
• Vascular dementia with combative behavior
• Vascular dementia with violent behavior

Don’t miss: A note under F01.51 instructs you to report an additional code, if applicable, to identify wandering in vascular dementia (Z91.83).

Understand Diagnostic Procedures for Vascular Dementia

Question 4: How will my neurosurgeon diagnose vascular dementia?

Answer 4: Your neurosurgeon will arrive at a diagnosis of vascular dementia based upon a complete history and an evaluation of the patient’s signs and symptoms. This service will include a complete mental status examination, a complete psychiatric and medical history of the patient and family, a review of systems (ROS), and ordering and interpreting neuropsychological and other diagnostic tests such as a Folstein Mini Mental Status Examination and Geriatric Depression Scale (GDS).

Your neurosurgeon will also assess the patient for behavioral problems that co-exist with dementia.

Don’t miss: Your neurosurgeon may also order laboratory tests such as CBC, ESR, blood sugar, liver and kidney function tests, thyroid function test, and tests for vitamin B-12 or folate to rule out other causes for dementia. Your surgeon might also ask for an MRI or CT of the brain to confirm the diagnosis of vascular dementia. The surgeon might subject the patient to other tests such as echocardiography and Holter monitoring to assess the patient for stroke.

Watch for These Vascular Dementia Symptoms

Question 5: What are some of the symptoms of vascular dementia?

Answer 5: Some of the common signs and symptoms of vascular dementia include paranoia, hallucinations, delusions, confusion, mood swings, reduced ability to perform day-to-day activities, memory loss, slurred speech, tremors, weakness in the extremities, and urinary incontinence.