2025 ICD-10-CM code F02.A1
Dementia in other diseases classified elsewhere, mild, with behavioral disturbance.
Medical necessity is established by demonstrating the direct link between a diagnosed physiological condition and the manifestation of mild dementia with behavioral disturbance. Clear documentation of cognitive decline and behavioral changes is crucial.The documentation should support the diagnosis and treatment plan.
The clinician's role is to accurately diagnose the underlying physiological condition causing the dementia and to appropriately assess and document the severity of the dementia and behavioral disturbances.
- Mental, Behavioral and Neurodevelopmental disorders (F01-F99)
- F02-F09: Mental disorders due to known physiological conditions. These disorders share a common cause: a demonstrable problem in the brain, such as disease, injury, or other damage leading to brain dysfunction.This dysfunction can be direct (primary), or a side effect from a condition affecting other body parts as well as the brain (secondary).
In simple words: This code indicates mild stage dementia with changes in behavior caused by a medical condition affecting the brain. It's used when the cause isn't Alzheimer's or similar problems, and the specific medical issue causing the dementia is coded separately.
This code represents mild dementia with behavioral disturbances stemming from a physiological condition other than those explicitly classified for dementia (e.g., Alzheimer's, vascular dementia).The underlying physiological condition should be coded first.
Example 1: A patient with a history of traumatic brain injury now presents with mild memory loss, difficulty concentrating, and increased irritability.The physician diagnoses mild dementia due to the prior injury, with behavioral disturbance, and codes F02.A1, with the traumatic brain injury code (S06.-) listed first., A patient with Huntington's disease (G10) develops mild dementia with accompanying agitation and emotional lability.The physician codes G10 first, followed by F02.A1 to specify the dementia with behavioral disturbance., A patient with long-standing hypothyroidism (E03.9) exhibits mild cognitive decline and significant changes in behavior, including apathy and social withdrawal. The clinician would first code the hypothyroidism, then F02.A1.
Documentation should clearly establish the causal relationship between the underlying physiological condition and the dementia, the presence and nature of behavioral disturbances, and the severity level as mild. Cognitive assessments, behavioral observations, and details of the underlying condition are essential.
** Excludes1: mild neurocognitive disorder due to known physiological condition with or without behavioral disturbance (F06.7-). Excludes2: dementia in alcohol and psychoactive substance disorders (F10-F19 with .17, .27, .97), and Vascular dementia (F01.-).
- Specialties:Neurology, Psychiatry, Internal Medicine, Geriatrics
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Nursing Facility, Skilled Nursing Facility,Hospice