Ophthalmology and Optometry Coding Alert

Report Dementia With Enhanced Specificity

Brain injury and illness, with a focus on dementia-related diagnoses, occupy a sizable portion of the 2023 changes to the ICD-10-CM code set. The major modifications to Chapter 5, Mental, Behavioral and Neurodevelopmental disorders, involve the expansion of options for reporting dementia to include severity and type of disturbance.

The updates for 2023 in category F01.- (Vascular dementia) include a few revisions and a significant code boost, with 29 new codes. Code F01.5- (Vascular dementia, unspecified severity) and the codes that fall under it are all revised to include the verbiage “unspecified severity.” And revised code F01.51- (Vascular dementia, unspecified severity, with behavioral disturbance) is converted to a parent and now leads to two new codes, so you can specify “with agitation” or “other behavioral disturbance.” ICD-10-CM 2023 also adds codes to identify the presence of psychotic disturbance, mood disturbance, or anxiety.

Putting it all together, here are the new codes you’ll turn to for reporting vascular dementia with unspecified severity beginning October:

• F01.5- (Vascular dementia, unspecified severity)
• F01.50 (… without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety)
• F01.51- (… with behavioral disturbance)
• F01.511 (… with agitation)
• F01.518 (… with other behavioral disturbance)
• F01.52 (… with psychotic disturbance)
• F01.53 (… with mood disturbance)
• F01.54 (… with anxiety)

Other expansions to this code group include the addition of codes for mild (F01.A-), moderate (F01.B-), and severe (F01.C-) vascular dementia, all of which break down into the classifications above, as well. You’ll also find revisions to categories F02.- (Dementia in other diseases classified elsewhere) and F03.- (Unspecified dementia), which now include those same code modifications and additions regarding severity and type of disturbance.

Instructions: ICD-10-CM Official Guidelines for 2023 will have an additional section devoted to dementia. New Section I.C.5.d says, “Selection of the appropriate severity level requires the provider’s clinical judgment and codes should be assigned only on the basis of provider documentation … unless otherwise instructed by the classification. If the documentation does not provide information about the severity of the dementia, assign the appropriate code for unspecified severity.”

Intracranial Injuries Get Big Code Bump

ICD-10-CM 2023 also introduces new codes for concussion, traumatic brain injury (TBI), cerebral edema, and hemorrhage when it is not known whether the patient lost consciousness. These conditions may affect eyesight and cause blurry or double vision, visual impairment, or other symptoms for which people may see your ophthalmologist.

Here are the new codes you’ll need to learn before Oct. 1:

• S06.0XA- (Concussion with loss of consciousness status unknown)
• S06.1XA- (Traumatic cerebral edema with loss of consciousness status unknown)
• S06.2XA- (Diffuse traumatic brain injury with loss of consciousness status unknown)
• S06.30A- (Unspecified focal traumatic brain injury with loss of consciousness status unknown)
• S06.34A- (Traumatic hemorrhage of right cerebrum with loss of consciousness status unknown)
• S06.35A- (Traumatic hemorrhage of left cerebrum with loss of consciousness status unknown)
• S06.36A- (Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness status unknown)
• S06.5XA- (Traumatic subdural hemorrhage with loss of consciousness status unknown)
• S06.6XA- (Traumatic subarachnoid hemorrhage with loss of consciousness status unknown)

Remember this: Before you use these codes, be sure to pay attention to the instructional note that accompanies the S06.- (Intracranial injury) group that tells you to use an additional code to identify mild neurocognitive disorders due to a known physiological condition using one of the new F06.7- (Mild neurocognitive disorder due to known physiological condition) codes, if applicable.

Also, as with most external cause codes, you’ll add a 7th character to these new codes — A (... initial encounter), D (… subsequent encounter), or S (… sequela) — to indicate the type of encounter.

Beware: Assignment of the 7th character for initial versus subsequent encounter has caused some confusion. A patient could be seen to follow up on a condition, and it’s still considered an initial encounter. Chapter 19 of the ICD-10-CM code book instructs that you use the 7th character:

• Initial encounter (A) for each encounter in which the patient is receiving active medical or surgical treatment for the condition.
• Subsequent encounter (D) for encounters after the patient has completed active treatment and is receiving routine care for the condition during the healing and recovery phase.

Example: Consider a patient with corneal abrasion on his right eye. During the initial encounter, the doctor examined the eye and prescribed an antibiotic eye drop for the patient to use twice a day. For this visit, the appropriate ICD-10-CM code is S05.01XA (Injury of conjunctiva and corneal abrasion without foreign body, right eye, initial encounter).

When following up two days later, the ophthalmologist finds the abrasion is not healing as expected. The initial prescription is discontinued, and a new medication is started. Because the patient is still receiving active treatment, the same diagnosis code applies because this is still considered an initial encounter, says Mary Pat Johnson, COMT, CPC, COE CPMA, senior consultant with Corcoran Consulting Group.