Geriatric Medical Coding – Coding for Dementia

Geriatric medicine involves health concerns of the elderly population, and these cover a number of syndromes and conditions. Dementia, urinary incontinence, osteoarthritis, diabetes, cardiovascular diseases, cerebrovascular diseases, hypertension, hearing concerns, and hyperthyroidism are some of the major conditions. Geriatricians carry out various examinations and offer counseling sessions for their patients. Practitioners in this field also screen patients for various psychosocial concerns.

Dementia Codes – Medical and Psychiatric Codes

Dementia is a condition that affects a number of old people and it is defined as the progressive and severe impairment of one’s brain function that interferes with one’s normal functioning. Dementia is usually irreversible. It may be mild, moderate, severe or profound.

The new codes for dementia are provided in ICD-10 Chapter V: Mental and Behavioural Disorders. These codes signify various types of dementia and include medical codes and psychiatric codes. When billing for dementia, service providers should give the correct diagnostic codes for medical conditions causing irreversible dementia such as:

• Alzheimer’s disease

• Frontotemporal dementia

• Multi-infarct dementia

• Parkinson’s disease with dementia

• Huntington’s disease

• Leukoencephalopathies

• Senile degeneration of the brain

• Mild cognitive impairment

• Dementia with Lewy bodies

• Pick’s disease

• Binswanger’s disease

• Creutzfeldt-Jakob disease

• Multiple sclerosis


• Neurosyphilis

• Unspecified cerebral degeneration

• Memory loss and late effects of CVD

Psychiatric codes signify uncomplicated senile dementia, presenile dementia, senile dementia with delusional features, senile dementia with depressive features, senile dementia with delirium, arteriosclerotic dementia, dementia without behavioral disturbances, and dementia with behavioral disturbances. When coding, it is necessary to indicate whether the dementia occurred with or without behavioral disturbances such as violent behavior, aggressive behavior, wandering off and more.

Reversible types of dementia are treatable and are most often caused by conditions such as brain tumors, chronic alcoholism, infections, certain deficiencies, heavy-metal poisoning, hyperthyroidism and so on. Providers can bill for pharmacologic, physical, occupational, speech-language and other therapies that are provided for their dementia patients. Payers require that providers clearly enter their primary diagnosis as well as the secondary diagnosis that support the medical necessity of the services provided. In case the patient suffers from an illness or injury not related to their dementia, the physician’s primary diagnosis recorded in the claim should reflect clearly the need for the billed service.

Factors that Have an Impact on Reimbursement

• CMS does not regard certain diagnostic codes as regular medical codes. As a result, these are not reimbursed at the usual rate, sometimes these are not paid at all. The provider has to have in-depth knowledge regarding the assignment of the correct primary and secondary diagnostic codes to ensure full reimbursement.

• Reporting all professional services in all settings such as inpatient, outpatient, home and nursing facilities, correctly using the appropriate CPT five digit codes

• Appropriate use of evaluation and management (E/M) codes or the five digit codes used to report non-procedural professional services. These codes should clearly highlight the complexity of the service provided. Tests such as gait and balance assessment, mini mental status exam, history, physical and family interview do not have their own CPT codes. So these are included under E/M.

A physician’s interaction with the patient includes screening, procedure visit and visit for discussing results. For effective reimbursement, the correct diagnostic and procedural codes have to be assigned for each of these visits. During screening, the physician identifies the condition for which the appropriate diagnostic code has to be assigned. Any new problem that requires a differential diagnosis has to be documented during the procedure visit. The provider has to also ascertain whether requirements for a higher level code are met. Additional documentation includes valid diagnostic codes to justify a comprehensive exam, codes to report any co-existing conditions such as diabetes, weight loss, delirium and so on. This is important with regard to using higher levels of E/M coding. In the case of a patient with multiple problems, the doctor will have to spend more time to complete the assessment. It is the visit’s complexity that would justify billing for the highest level E/M.

• 99205 – Level 5 comprehensive exam for new patient

• 99215 – Level 5 comprehensive exam for established patient

• 96116 – neurobehavioral status examination

Codes to Use for Care Management Provided

• First hour – 99358

• Each additional 30 minutes – 99359

• Telephone services – 99371-3

Tips for Accurate Coding

Review of systems (ROS), history of present illness (HPI), family, physical examination, social medical history, medical decision making, time spent for discussion of counseling, and organizing care, all these have to be taken into account when assigning E/M codes. When coding for dementia, under no circumstances should a lower level of service be reported using a higher level code. If you are to receive due reimbursement, medical necessity of a provided service is of course the primary consideration. Individual requirements of the CPT codes used are also a major criterion. The level of service reported should have sufficient supporting documentation.