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2025 ICD-10-CM code F02.B

Dementia in other diseases classified elsewhere, moderate.

Always code the underlying physiological condition first.Ensure the severity of the dementia accurately reflects the patient's clinical presentation.Use additional codes to specify the type of dementia if known.Refer to ICD-10-CM guidelines for detailed coding instructions.

The medical necessity for this code is established by the presence of moderate dementia secondary to a documented physiological condition that negatively impacts the patient's daily functioning and quality of life.

Diagnosis and management of the dementia and the underlying physiological condition.

IMPORTANT:Code first the underlying physiological condition.Consider codes for specific dementia types (e.g., Alzheimer's disease, vascular dementia) if known.Excludes mild neurocognitive disorder (F06.7), dementia in alcohol or substance use disorders (F10-F19), and vascular dementia (F01.5-).

In simple words: This code describes a moderate level of dementia caused by a medical condition that's not directly named here, such as Alzheimer's disease or a stroke.Doctors will also code the actual condition that is causing the dementia.

This code signifies moderate dementia resulting from a known physiological condition, but not explicitly specified.It's crucial to code the underlying cause first (e.g., Alzheimer's disease, stroke, HIV infection). This classification includes cognitive decline affecting memory, thinking, and judgment, of moderate severity. The underlying condition must be documented separately.Excludes mild neurocognitive disorder due to a known physiological condition, dementia in alcohol or substance use disorders, and vascular dementia.

Example 1: A 70-year-old patient presents with progressive memory loss, difficulty with daily tasks, and changes in personality.Further investigation reveals moderate dementia due to Alzheimer's disease.Codes: G30.9 (Alzheimer's disease, unspecified type), F02.B (Dementia in other diseases classified elsewhere, moderate), A 65-year-old patient experiences a significant stroke leading to moderate cognitive impairment, affecting memory and executive function. Codes: I61.9 (Unspecified cerebral infarction), F02.B (Dementia in other diseases classified elsewhere, moderate), A 55-year-old patient with HIV infection develops moderate dementia as a complication of the disease. Codes: B20 (HIV disease), F02.B (Dementia in other diseases classified elsewhere, moderate)

Detailed history of cognitive decline, including onset, progression, and specific symptoms.Comprehensive neuropsychological testing results.Documentation of the underlying medical condition.Imaging studies (e.g., MRI, CT) if performed.Laboratory results pertinent to the underlying condition.

** This code should be used cautiously, always ensuring the primary underlying cause is correctly coded.Clinical documentation must support the diagnosis of moderate dementia and identify the related physiological condition to justify the code's use.

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