Renee Kinder

No two patients are the same.

Furthermore, therapists know well that no two patients with dementia are ever the same.

We have long awaited greater specificity in coding for the persons we serve daily with dementia and now we finally have the opportunity to code specifically tied to severity.

How, you ask? Well, the FY 2023 ICD-10 updates are now in effect. 

Therapists and the interdisciplinary team should take note of the added specificity we have long awaited to coding for dementia.

The Centers for Medicare & Medicaid Services and the National Center for Health Statistics, two departments within the federal government’s Department of Health and Human Services provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) effective 10-1-2023.

The guidelines should be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website. The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reasons for visits in all health care settings. 

The ICD 10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO). 

Furthermore, guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association, the American Health Information Management Association, CMS and NCHS. 

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. 

The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

So, what is new to Chapter 5: Mental, Behavioral and Neurodevelopmental disorders (F01 – F99)?

Over 80 new and updated codes provide greater specificity based on etiology and levels of severity (mild, moderate, severe, or unspecified).

The updated ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate or severe). 

Selection of the appropriate severity level requires the provider’s clinical judgment and codes should be assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), 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. If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.

For example: Mild F02.A0, with

– aberrant motor behavior (exit-seeking) (pacing) (restlessness) (rocking) F02.A11

– -agitation F02.A11

–  anxiety F02.A4

– behavioral disturbances (sexual disinhibition) (sleep disturbance) (social disinhibition) F02.A18

– specified NEC F02.A18

–  mood disturbance (anhedonia) (apathy) (depression) F02.A3

–  psychotic disturbance (delusional state) (hallucinations) (paranoia) (suspiciousness) F02.A2

– verbal or physical behaviors (anger) (aggression) (combativeness) (profanity) (shouting) (threatening) (violence) F02.A11

Moderate F02.B0, with

–  aberrant motor behavior (exit-seeking) (pacing) (restlessness) (rocking) F02.B11

– -agitation F02.B11

– anxiety F02.B4

–  behavioral disturbances (sexual disinhibition) (sleep disturbance) (social disinhibition) F02.B18

–  specified NEC F02.B18

–  mood disturbance (anhedonia) (apathy) (depression) F02.B3

– psychotic disturbance (delusional state) (hallucinations) (paranoia) (suspiciousness) F02.B2

– verbal or physical behaviors (anger) (aggression) (combativeness) (profanity) (shouting) (threatening) (violence) F02.B11

Severe F02.C0, with

– aberrant motor behavior (exit-seeking) (pacing) (restlessness) (rocking) F02.C11

– agitation F02.C11

– anxiety F02.C4

– behavioral disturbances (sexual disinhibition) (sleep disturbance) (social disinhibition) F02.C18

– specified NEC F02.C18

-mood disturbance (anhedonia) (apathy) (depression) F02.C3

-psychotic disturbance (delusional state) (hallucinations) (paranoia) (suspiciousness) F02.C2

– verbal or physical behaviors (anger) (aggression) (combativeness) (profanity) (shouting) (threatening) (violence) F02.C11

Ready to learn more?

FY 2023 rules can be found on the CDC and CMS websites with more detail here

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected]