Coding case study: Dementia

Published on: 
Medical Economics Journal, Medical Economics October 2020, Volume 97, Issue 14

Are you missing out on revenue because of improper coding?

Getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. This scenario involves a patient presenting with symptoms of dementia; see if you can choose the correct codes.

Clinical Scenario

Chief complaint

Resident is followed for Dementia, Hypertension, HLD, anxiety, insomnia, and debility. Meds reviewed and updated. Resident continues to be in long term care at facility. Labs reviewed and will be ordered as clinically indicated. Res denies c/o pain.

Review of Systems

Constitutional: Positive for activity change.

HENT: Positive for trouble swallowing.

Eyes: Negative.

Respiratory: Positive for cough and shortness of breath.Aspiration PNA

Cardiovascular: Negative for leg swelling. HTN

GI: Positive for constipation.

Endocrine: Negative.

Genitourinary: Negative.

Musculoskeletal: Positive for back pain and gait problem.

Skin: Negative.

Allergic/Immunologic: Negative.

Neurological: Positive for weakness.

Psychiatric/Behavioral: Positive for confusion and sleep disturbance.

Social History

Smoking status: Quit 5 years ago

Types: Cigarettes

No known allergies

Encounter Medications

Acetaminophen (Tylenol) 325 mg tablet, Take 650 mg by mouth 3 (three) times daily Maximum dose of acetaminophen is 4,000 mg from all sources in 24 hr

ARIPiprazole (Abilify) 2 mg tablet, Take 4 mg by mouth daily

Donepezil (Aricept) 10 mg tablet, Take 10 mg by mouth, Nightly

Hydrocortisone 0.5 % cream, Apply topically 2 (two) times daily, Apply to rash

Lorazepam (Ativan) 0.5 mg tablet, Take one tablet (0.5 mg total) by mouth daily, 30 tablet

Magnesium hydroxide (Milk of Magnesia) 400 mg/5 mL suspension, Take 30 mLs by mouth nightly as needed for constipation

Trazadone 50 mg tablet. Take 100 mg by mouth nightly.

Physical Exam

Constitutional: He appears well-developed.

Head: Normocephalic and atraumatic.

Eyes: EOM are normal. Pupils are equal, round, and reactive to light.

Neck: Normal range of motion. Neck supple.

Cardiovascular: Normal rate, regular rhythm and intact distal pulses.

Pulmonary/Chest: Effort normal and breath sounds normal. o2 sats 95%

Abdominal: Soft. Bowel sounds are normal.

Musculoskeletal: He exhibits no edema, Moves all extremities independently

Neurological: He is alert, Oriented x1, Able to follow simple commands

Skin: Skin is warm and dry, Noted right ankle wanderguard intact

Psychiatric: Cognition and memory are impaired.

Nursing note and vitals reviewed.

Assessment and Plan

Late onset Alzheimer’s disease without behavioral disturbance



Generalized anxiety disorder

Insomnia, unspecified type

Weakness generalized

Continue meds and therapy as ordered

Meds reviewed and updated

Resident to continue to be in long term care at facility

Documentation Coding Requirements

When documenting dementia, include the following:

With or without behavior disturbance


Sedative, hypnotic or anxiolytic-induced


ICD-10 Codes for Dementia

Vascular dementia with behavioral disturbance P

Vascular dementia without behavioral disturbance P

Dementia in other diseases classified elsewhere without
behavioral disturbance P

Dementia in other diseases classified elsewhere with
behavioral disturbance PP

Unspecified dementia without behavioral disturbance

Unspecified dementia with behavioral disturbance P

Alcohol dependence with alcohol-induced
persisting dementia P

Alcohol use, unspecified with alcohol-induced persisting dementia P

Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced
persisting dementia

Sedative, hypnotic or anxiolytic use, unspecified
with sedative, hypnotic or anxiolytic-induced
persisting dementia

Inhalant abuse with inhalant-induced dementia

Inhalant dependence with inhalant-induced dementia

Inhalant use, unspecified with inhalant-induced persisting dementia

Other psychoactive substance abuse with psychoactive substance-induced persisting dementia

Other psychoactive substance dependence with psychoactive substance-induced persisting dementia

Other psychoactive substance use, unspecified with psychoactive substance-induced persisting dementia

Other frontotemporal dementia P

Dementia with Lewy bodies P

Coding notes

Code first the underlying physiological condition or sequelae of cerebrovascular disease

Code first the underlying physiological condition, such as:

Alzheimer’s (G30.-), cerebral lipidosis (E75.4), Creutzfeldt-Jakob disease (A81.0-), dementia with Lewy bodies (G31.83), dementia with Parkinsonism (G31.83), epilepsy and recurrent seizures (G40-G40.B19), frontotemporal dementia (G31.09), hepatolenticular degeneration (E83.01), human immunodeficiency virus [HIV] disease (B20), Huntington’s disease (G10), hypercalcemia(E83.52), hypothyroidism, acquired (E01-E03.9), intoxications (T36-T65.94XS), Jakob-Creutzfeldt disease (A81.0-), multiple sclerosis (G35), neurosyphilis (A52.17), niacin deficiency [pellagra] (E52), Parkinson’s disease (G20), Pick’s disease (G31.01), polyarteritis nodosa (M30.0), prion disease (A81.9), systemic lupus erythematosus (M32-M32.9), traumatic brain injury (S06.-), trypanosomiasis (B56-B56.9, B57-B57.5, ), vitamin B deficiency (E53.8)

Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere (Z91.83)

Use additional code for blood alcohol level, if applicable (Y90.-)

Use additional code to identify dementia with behavioral disturbance (F02.81), dementia without behavioral disturbance (F02.80)

Diagnosis codes:


Alzheimer’s disease with late onset


Dementia in other diseases classified elsewhere without behavioral disturbance


Other malaise


Generalized anxiety disorder


Insomnia, unspecified