Posts Tagged ‘ICD-10’

Dementia, By Any Other Name, is Still Dementia

Tuesday, November 22nd, 2016

Have you adopted the DSM-5 nomenclature “major neurocognitive disorder”, or have you continued to use “dementia”, as I have? DSM-5 was released in 2013, introducing neurocognitive disorders, major and minor. In the years since, I’ve noticed that many psychiatrists, but not all, have adopted the new nosology. But other physicians, including primary care physicians and neurologists, and most geriatric psychiatrists, still use “dementia”. And ICD-10 uses the tried and true term “dementia”. Nevertheless, as a medical school faculty member, responsible for the training of medical students, residents, and fellows, I suppose I should toe the DSM-5 line, but I’m not going to do it. It’s a pet peeve.

It’s almost 2017, and you might wonder what took me so longer to get around to expressing my objections to the reclassification of dementia as a neurocognitive disorder. Fair question. Suffice to say I’ve been busy. “What could have been more important this this?” you ask. For one, there’s Medicare, moving target par excellence, source of endlessly changing rules, regulations, and (dis)incentives, and general bane of existence. And then there’s my book, Beat Depression to Stay Healthier and Live Longer: A Guide For Older Adults and Their Families, published earlier this year. It’s a terrific book and easy to read, if I do say so myself. I assure you that nary a page deals with ICD-10, but there is a terrific chapter, suitable for the lay public and clinicians alike, on the differential diagnosis of depression, covering the different types of depression, other conditions that masquerade as depression, and how to tell them apart. Ironically, I used DSM-5 terminology. I’d highly suggest getting a copy: no, not DSM-5, my book! Even before you finish reading this post, you may wish to order it on amazon.com.  You won’t regret buying my book, but, back to DSM-5 and dementia.

First my “minor” major neurocognitive disorder objections. I simply like the term “dementia” better. It’s traditional, having been in use for well over 100 years. Healthcare professionals all know what it refers to, and much of the public does. And it’s shorter and easier to say. “Major neurocognitive disorder” doesn’t exactly roll off the tongue.

And now my “major” major neurocognitive disorder objections. Actually I don’t object to “neurocognitive” for the category of syndromes, generally, but I don’t see the advantage for dementia specifically. True, “neurocognitive” does describe a major aspect of dementia. But is also seems too narrow, the most disruptive and disabling manifestations of dementia being their psychiatric and behavioral complications. And, and the same time, it also seems non-specific, schizophrenia clearly also being a disorder involving severe neurocognitive impairment. Had they asked me, I’d have suggested letting dementia be dementia, and calling the category of disorders “acquired disorders of widespread brain impairment usually first manifest in late life”. Nobody asked me, but, no matter, there’s always DSM-6 to look forward to.

What do you think? Send me a comment, and let’s start a discussion.   If you’d like to receive my online newsletter, please navigate to the contact page and leave your email address.

ICD-10 CODING FOR PSYCHOSIS IN ALZHEIMER’S DISEASE

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.

Background

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.

Disclaimer

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