Wiki Vascular dementia coding order

[JRae5M]

The 2019 ICD-10-CM Expert lists a "Code first" rule for vascular dementia: "Code first the underlying physiological condition or sequelae of the cerebrovascular disease."
Based on this, the Provider has submitted the following:
(I10) Essential (primary) hypertension
(F01.50) Vascular dementia w/o behavioral disturbance

Billing is rejecting (I10) as a primary diagnosis based on the LCD for CPT 90792. I spoke to billing and explained that Vascular dementia is the primary DX and is on the LCD for CPT 90792,
and that the first-listed diagnosis is there per ICD-10-CM coding rules.

Does anyone have experience with this? Thank you.

 

[thomas7331]

The 2019 ICD-10-CM Expert lists a "Code first" rule for vascular dementia: "Code first the underlying physiological condition or sequelae of the cerebrovascular disease."
Based on this, the Provider has submitted the following:
(I10) Essential (primary) hypertension
(F01.50) Vascular dementia w/o behavioral disturbance

Billing is rejecting (I10) as a primary diagnosis based on the LCD for CPT 90792. I spoke to billing and explained that Vascular dementia is the primary DX and is on the LCD for CPT 90792,
and that the first-listed diagnosis is there per ICD-10-CM coding rules.

Does anyone have experience with this? Thank you.

You're correct in that per coding conventions the etiology code must be first-listed and that F01.50 must be the secondary code. You would need to inquire as to where billing got their directive and what the rationale is, or you may be able to simply instruct them to override or bypass the rejection that they have received, if they are able to do that - billing edits are not always correct, and the fact that the code is secondary, in and of itself, should not matter for an LCD. On the other hand, the payer may be looking for a more accurate etiology code for this condition. Hypertension does not directly cause vascular dementia, but rather may cause a vascular disease or condition which in turn leads to the dementia. The payer may be requiring a hypertensive vascular disease code that more accurately reflects the specific disease process that caused the dementia and if so, it may be necessary to query the provider for clarification.