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2025 ICD-10-CM code F02.B11

Moderate dementia due to a known physiological condition, accompanied by agitation.

The dementia code should be assigned based on provider documentation of severity.If the documentation doesn't specify the severity, use a code for unspecified severity.

Medical necessity is established by the presence of a documented physiological condition causing moderate dementia and the presence of agitation impacting the patient's daily life and requiring medical intervention.

The healthcare provider must document and assess both the underlying physiological condition causing the dementia and the severity of the cognitive decline, along with the presence and nature of agitation. This ensures accurate coding and facilitates appropriate management and care planning for the patient.

In simple words: This code indicates a moderate stage of memory and thinking problems caused by a physical condition, along with feelings of restlessness or anxiety.

Dementia in other diseases classified elsewhere, moderate, with agitation.This code signifies a moderate level of dementia resulting from a physical or medical condition, not a primary psychiatric illness. The dementia is further characterized by agitation, which may manifest as restlessness, pacing, or emotional distress.

Example 1: A patient with moderate Parkinson's disease experiencing memory loss and confusion, coupled with increased restlessness and irritability., A patient with a history of moderate traumatic brain injury now exhibiting cognitive decline and frequent agitated outbursts. , A patient with Huntington's disease showing moderate cognitive impairment and demonstrating repetitive, restless movements and emotional lability.

Documentation should include: 1. The underlying physiological condition responsible for the dementia. 2. Clinical evidence supporting the diagnosis of moderate dementia (e.g., cognitive assessments, functional limitations). 3. Detailed description of agitation symptoms.

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