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2025 ICD-10-CM code F02.811

Dementia in other diseases classified elsewhere, unspecified severity, with agitation.

The underlying physiological condition should be coded first, followed by code F02.811.

Medical necessity must be established by demonstrating a direct causal relationship between the underlying disease and the observed dementia with agitation.The documentation should support the need for interventions and management specifically related to these conditions.

The clinician is responsible for diagnosing the underlying cause of dementia, assessing its severity, and documenting the presence of agitation along with other behavioral disturbances. Accurate and detailed documentation is crucial for proper coding and subsequent care planning.

IMPORTANT:If the dementia is due to alcohol or substance use, consider codes F10-F19 with .17, .27, or .97.For vascular dementia, use F01.5-, F01.A-, F01.B-, or F01.C-. If wandering is also present, use Z91.83.

In simple words: This code refers to a situation where a person has dementia caused by a medical problem other than those specifically listed for dementia, and they are also restless or agitated.

This code describes a patient with dementia caused by a disease classified elsewhere, with an unspecified level of severity, and exhibiting agitation.The underlying physiological condition causing the dementia needs to be coded separately.

Example 1: A patient with Parkinson's disease (G20) experiences cognitive decline and accompanying periods of restlessness and agitation.The Parkinson's disease is coded as G20, and the dementia with agitation is coded as F02.811., A patient with a traumatic brain injury (S06.-) develops dementia. The patient displays agitation.The traumatic brain injury is coded with the appropriate S06 code, and the dementia with agitation is coded as F02.811., A patient with Huntington's disease (G10) develops dementia and becomes agitated.Huntington's disease is coded as G10, and the dementia with agitation is coded as F02.811.

Documentation should clearly link the dementia to the underlying condition. It must describe the agitation exhibited by the patient, including its frequency, severity, and impact on daily functioning.The clinician's assessment of the dementia's severity (if possible) should also be documented.

** For accurate and complete documentation, use a validated cognitive assessment tool and describe the specific behaviors associated with the agitation. Consider a referral to specialized services (e.g., behavioral health) as needed.

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