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2025 ICD-10-CM code F02.A2

Mild neurocognitive disorder due to a known physiological condition, with psychotic disturbance.

Code first the underlying physiological condition causing the dementia. Do not use this code for dementia due to alcohol or substance use (F10-F19 with .17, .27, .97) or vascular dementia (F01.5-, F01.A-, F01.B-, F01.C-).

Medical necessity is established by demonstrating the presence of a known physiological condition causing the dementia and documenting the impact of the cognitive decline and psychotic symptoms on the patient's daily life and functioning.

Clinicians must first identify and code the underlying physiological condition responsible for the dementia. Thorough documentation of the psychotic disturbances, including their nature, frequency, and impact on the patient's functioning, is crucial for accurate coding.

In simple words: This diagnosis is for a mild form of dementia caused by a medical problem, where the person experiences things like hallucinations or paranoia.

This code represents a mild stage of dementia caused by a physical condition, accompanied by psychotic symptoms like hallucinations, delusions, paranoia, or suspiciousness.It is important to code the underlying physiological condition first.

Example 1: A patient with a history of Parkinson's disease (G20) develops mild cognitive impairment with hallucinations. The Parkinson's disease is coded first (G20.-), followed by F02.A2 to specify the dementia with psychotic disturbance., A patient with a history of traumatic brain injury (S06.-) now exhibits mild dementia and paranoia. The traumatic brain injury is coded first (S06.-), followed by F02.A2., A patient diagnosed with Huntington's Disease (G10) presents with mild cognitive decline and delusional beliefs. Huntington's Disease (G10) is coded first, followed by F02.A2 to capture the dementia with psychosis.

Documentation should clearly link the dementia and psychotic symptoms to the underlying physiological condition. Details of cognitive assessments, mental status examinations, and observed psychotic behaviors should be included. The documentation should also specify the severity of the dementia as "mild".

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