Posts Tagged ‘Alzheimer’s disease’

Think Medications for Dementia Produce No Meaningful Benefit? Don’t Be So Sure

Saturday, January 14th, 2017

Currently available anti-Alzheimer drugs – donepezil (Aricept), galantamine (Razadyne), rivastigmine (Exelon), and memantine (Namenda) – are not the miracle cures patients hope for, and many clinicians are skeptical, and don’t prescribe them. Consumers nevertheless have heard that these drugs at least “slow it down”, and many accept this as better than nothing.

But do anti-Alzheimer medications “slow it down”? Unfortunately, scientists do not know for sure. Some research demonstrates actions in the brain of anti-Alzheimer drugs that could be helpful, but there has been no proof that these effects interrupt the disease process. Specialists who recommend these medications mostly believe that their benefits are limited to temporary improvement of symptoms, stabilizing their patients’ conditions for a time, before they resume relentlessly losing ground to dementia. What remains unknown is whether treated patients continue to decline at the same rate as before or slower. A new study provides reason to think that anti-Alzheimer drugs actually might slow down patients’ decline.

Last month French researchers published a study of patients with mild cognitive impairment.*  Mild cognitive impairment (you may hear it referred to as mild neurocognitive disorder) is a milder condition not severe enough to be considered a dementia. About half of the time, however, MCI is a preliminary stage of Alzheimer’s disease: such patients gradually get worse and sooner or later develop dementia.

In this French study, patients with MCI were treated for one year: half received donepezil (Aricept) and half placebo. At the beginning of the study, and again at the end of the year, patients had brain MRI scans, and the thickness of their cerebral cortex was measured. The cortex is the outer layer of the brain, where memory and other higher mental abilities reside. As Alzheimer’s disease worsens the cerebral cortex gets thinner and thinner. Researchers compared the amount of thinning in those who received donepezil with those who did not. The good news is that the patients treated with donepezil had much less cortical thinning than those who received placebo. In some brain areas, the cortex even got thicker! This finding suggests that treatment with anti-Alzheimer medications may actually slow down the rate at which patients decline

While encouraging, this study has many weaknesses, so it is far from a slam-dunk proof of anything. But it does provide another bit of evidence that anti-Alzheimer drugs may not be as worthless as many think. If these drugs do slow the rate of decline, the benefit might not be apparent early in treatment, but would be more and more obvious, and meaningful, as time goes on because patients stay further and further ahead of where they would have been without treatment. This is a different way to think about medical treatment, but nonetheless a meaningful one, especially for Alzheimer patients and their families.


Monday, October 24th, 2016

Here’s a common question:  What is the proper ICD-10 code for psychosis in Alzheimer’s disease?

The Bottom Line

Here are the appropriate diagnoses in the order they should be listed on your claim form:

G30.1, Alzheimer’s disease, late onset (G30.0 for early onset)

F06.2, psychotic disorder with delusions due to a known physiologic condition

F02.81, Dementia in other diseases classified elsewhere, with behavioral disturbance.

Read on if you’d like a more detailed explanation and an ICD-10 pearl.


Prior to DSM-IV-TR, 290.20 was the accepted code for dementia of the Alzheimer’s type, with delusions.  Using this code was straightforward: it was the only code you needed, and it was both a DSM-IV AND an ICD-9 code, so you couldn’t go wrong (Recall that Medicare accepts ICD codes, and does not recognize DSM).  Since the advent of ICD-10, many psychiatric providers, long accustomed to entering a single diagnostic code, have been using F02.81, dementia in diseases elsewhere classified, with behavioral disturbance.  The problem with this is that, standing alone, this code does not adequately capture the intensity of service usually required to treat the psychiatric complications of Alzheimer’s disease, especially when hospitalization is warranted.   To appreciate why this is the case, we need to understand something about Part B Medicare reimbursement.

Medicare Claims Coding 101 

Original, fee-for-service Medicare has no prior authorization or concurrent review.  Claims are paid when the diagnosis code matches the CPT service code and level of service provided, supporting the medical necessity of the services billed.  In a Medicare claim, the diagnosis essentially is a proxy for the reason for the service.

Consider the case of an elderly man with Alzheimer’s disease with paranoid delusions and homicidal ideation, admitted to a geriatric psychiatry inpatient unit for threatening his wife with a shotgun, convinced that she’s trying to poison him and run off with a lover he’s conjured up in his delusions.  He repeatedly expresses his intention to kill her, and there is no doubt that psychiatric hospitalization is medically necessary.  But psychosis with homicidal dangerous is the reason, not Alzheimer’s disease.  F02.81, dementia in diseases elsewhere classified, with behavioral disturbance doesn’t convey this effectively: it’s nonspecific, saying nothing about symptoms, severity, or acuity.  Fortunately, other ICD-10 codes can be added to paint a more vivid and representative picture.

ICD-10 Coding for Psychosis in Alzheimer’s Disease

The F06 series of codes, other mental disorders due to known physiologic condition, can be used to code the various psychiatric complications of dementia.  This group includes distinct codes for mood disorders, both depression and mania, anxiety, and psychosis. There are three codes for psychotic illness that might apply to psychosis in Alzheimer’s disease: F06.0, psychotic disorder with hallucination due to known physiological condition, F06.1, catatonic disorder due to known physiological condition, and F06.2, psychotic disorder with delusions due to known physiological condition.  It is permissible to code as many as apply; up to twelve diagnoses can be listed in an ICD-10-compliant claim. In our hypothetical case, we would add FO6.2 to the diagnoses.

We’re not done yet.  Both F02.81 and F06.0 are manifestation codes, meaning they are conditions caused by one or more specific etiologies.  ICD-10 distinguishes manifestation codes from etiology codes.  Manifestation codes are recognizable by phrases such as “in other diseases classified elsewhere”.  Whenever you use a manifestation code, you must accompany it with one or more etiology codes, and these must be listed first.  Dementia is a syndrome with multiple causes so F02 is thus a manifestation code.  In our hypothetical case scenario, the underlying diagnosis is Alzheimer’s disease with late onset, the ICD-10 etiology code for which is G30.1. Two other common causes of dementia that have etiology codes that pair with F02 are G31.0, frontotemporal dementia, and G31.83, dementia with Lewy bodies.

Here’s an additional coding pearl.  In ICD-10 there is a code “homicidal ideations”, R45.850.  Surprisingly, this code is nowhere to be found in DSM-V, not even in the appendix of relevant ICD-10 diagnoses.  No matter, we can use it. Adding it to the diagnoses helps your claim more fully reflect the medical necessity of the services rendered.  So, this is how you could list your diagnostic codes for our patient:

G30.1, Alzheimer’s disease, late onset

F06.2, psychotic disorder with delusions due to a known physiologic condition

R45.850, homicidal ideations

F02.81, Dementia in other diseases classified elsewhere, with behavioral disturbance.

Did You Find This Helpful?

If you found this post helpful, are there other topics in the area of Medicare billing you would like to see covered?  Please send me a message, letting me know, and, while you’re at it, tell me if you’d like to be added to the email list for the Moak Mental Health and Aging Report.


Information in this blog reflects my understanding of current Medicare rules and regulations.  I used these codes regularly in my practice, and encountered no problems, but following my advice is no guarantee of error-free coding and audit-free payment.  All providers are ultimately responsible for Medicare compliance and correctly coding their claims.  Good luck and godspeed!

Gary S. Moak, M.D.

Practice Management Consultant, Moak Associates

Author, Beat Depression to Stay Healthier and Live Longer: A Guide for Older Adults and Their Families

Assistant Professor of Psychiatry, Geisel Medical School at Dartmouth

Chief of Geriatric Psychiatry, New Hampshire Hospital