March 9, 2015

Alzheimer’s Disease – Improved Documentation Leads to Better Coding, Better Research

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EDITOR’S NOTE: Kathy Pride is continuing her reporting on diseases that have been covered in the national news media as they relate to ICD-10.The recent Academy Award winner Julianne Moore and her role in “Still Alice” have brought Alzheimer’s disease some much-warranted media attention – and for Pride, the film hit close to home.

In a March 4 press release, the National Institutes of Health (NIH) announced the launch of a new Alzheimer’s “big data” portal for use by the national medical research community. The new portal will enable sharing and analysis of large and complex biomedical data sets. In a statement by NIH Director Francis S. Collins, MD, PhD, Collins noted that “we are determined to reduce the cost and time it takes to discover viable therapeutic targets and bring new diagnostics affective therapies to people with Alzheimer’s. That demands a new way of doing business.”

This is welcome news to the Alzheimer’s community. With more than 5 million Americans living with the disease, there is a good chance that you are or have been personally affected by it. My mother is currently in the late stages of the disease, and my maternal grandmother died from Alzheimer’s. For my mother and grandmother, it is too late; however, my siblings and I worry about what that means for us and our odds of developing it – so for me, this is personal. 

According to the Alzheimer’s Association, Alzheimer’s disease is currently the sixth-leading cause of death in the United States. Although research has revealed a great deal about Alzheimer’s, much is yet to be discovered about the precise biological changes that cause Alzheimer’s, why it progresses at different rates among affected individuals, and how the disease can be prevented, slowed, or stopped.

One in nine people age 65 and older (11 percent) has Alzheimer’s disease. About one-third of people age 85 and older (32 percent) have Alzheimer’s. Of all of those with Alzheimer’s disease, the vast majority (82 percent) are 75 or older.

More women than men have Alzheimer’s and other forms of dementia. Almost two-thirds of Americans with Alzheimer’s are women – of the 5 million Americans aged 65 and older with Alzheimer’s, 3.2 million are women and 1.8 million are men. Based on estimates, among people 71 and older, 16 percent of women have Alzheimer’s disease and/or another form of dementia, compared with 11 percent of men. The observation that more women than men have Alzheimer’s disease and other dementias is primarily explained by the fact that women live longer, on average, than men – and old age is the greatest risk factor for Alzheimer’s.

What can we do as clinicians and coders to help in the battle to better understand this disease and contribute to research?  We can improve our documentation of diagnoses, which will lead to more accurate coding. Accurate coding leads to better data for research.

Our first step to better coding is better documentation. Simply documenting “Alzheimer’s” or “dementia” only allows the coder to select an unspecified code.

Alzheimer's is a disease that attacks the brain. It is the most common form of dementia. Dementia is a term for diseases and conditions characterized by a decline in memory or other thinking skills that affect a person’s ability to perform everyday activities. Dementia is caused by damage to nerve cells in the brain, which are called neurons. As a result of the damage, neurons can no longer function normally and may die. This, in turn, can lead to changes in one’s memory, behavior, and ability to think clearly. In Alzheimer’s disease, the damage to and death of neurons eventually impair one’s ability to carry out basic bodily functions such as walking and swallowing. People in the final stages of the disease are bed-bound and require around-the-clock care. Alzheimer’s disease is ultimately fatal. 

When an individual has symptoms of dementia, a physician must conduct tests to identify the underlying brain disease or other condition that is causing symptoms. Different types of dementia are associated with distinct symptom patterns and brain abnormalities. 

Alzheimer’s disease

This is the most common type of dementia; it accounts for an estimated 60 to 80 percent of cases. About half of these cases involve solely Alzheimer’s pathology; many have evidence of pathologic changes related to other dementias. This is called mixed dementia.

The following are common symptoms of Alzheimer’s:

• Memory loss that disrupts daily life

• Challenges in planning or solving problems

• Difficulty completing familiar tasks at home, at work, or at leisure

• Confusion with time or place

• Trouble understanding visual images and spatial relationships

• New problems with words in speaking or writing

• Misplacing things and losing the ability to retrace steps

• Decreased or poor judgment

• Withdrawal from work or social activities

• Changes in mood and personality, including apathy and depression

ICD-9-CM gave us one code for Alzheimer’s disease, 331.0. However, ICD-10-CM has expanded this category, giving us four choices:

  • G30.0 – Alzheimer’s disease  with early onset
  • G30.1 – Alzheimer’s disease with late onset
  • G30.9 – Other Alzheimer’s disease
  • G30.9 – Alzheimer’s disease, unspecified

Documentation of early versus late onset is required to code the Alzheimer’s to its highest level of specificity. At this time, there is no Coding Clinic guidance that will allow the coder to select early versus late onset based solely on a patient’s age; therefore, it is the provider’s documentation that will determine code selection. This distinction is important for research purposes. 

Instructional notes for category G30 tell us to use additional code to identify:

  • Delirium, if applicable (F05)
  • Dementia without behavioral disturbance (F02.80)
  • Dementia with behavioral disturbance (F02.81)

It is important to note that the dementia codes from category F02 and F05 should never be used as the primary diagnosis. Category F02’s description specifically reads “dementia in other diseases classified elsewhere.” The phrase “classified elsewhere” is the coder’s clue that this is a secondary diagnosis, and the documentation needs to support a primary diagnosis for the dementia in order to use a code from this category. In addition, the code for delirium (F05) has an instructional note as well an instruction for the coder to “code first the underlying physiological condition.” 

Other types of dementia include vascular dementia, dementia with Lewy bodies, and mixed dementia.

Vascular dementia

Previously known as multi-infarct or post-stroke dementia, vascular dementia is less common as a sole cause of dementia than Alzheimer’s, accounting for about 10 percent of dementia cases. However, it is very common in older individuals with dementia, with about 50 percent having pathologic evidence of vascular dementia (infarcts). In most cases, the infarcts coexist with Alzheimer’s pathology.

Coding for vascular dementia in ICD-10-CM has been simplified. In ICD-9-CM we had to know the type of behavioral disturbance (when applicable) in order to code to the highest level of specificity. In ICD-10-CM we are given two choices: 

  • F01.50 Vascular dementia without behavioral disturbances
  • F01.51 Vascular dementia with behavioral disturbances

Dementia with Lewy bodies (DLB)

People with DLB have some of the symptoms common in Alzheimer’s, but are more likely to have initial or early symptoms of sleep disturbances, well-formed visual hallucinations and slowness, gait imbalance or other Parkinsonian movement features. These features, as well as early visuospatial impairment, may occur in the absence of significant memory impairment. 

The ICD-10-CM code for dementia with Lewy bodies is G31.83. 

Mixed dementia

Characterized by the hallmark abnormalities of more than one type of dementia — most commonly

Alzheimer’s combined with vascular dementia, followed by Alzheimer’s with DLB, and Alzheimer’s with vascular dementia and DLB. Vascular dementia with DLB is much less common.  Recent studies suggest that mixed dementia is more common than previously recognized, with about half of those with dementia having mixed pathologies. However, there is no specific code for mixed dementia; therefore, it is important for the provider to document both the Alzheimer’s and the other type of dementia (e.g.  vascular dementia), as the conditions will be coded separately.

The bottom line is that documentation of the type(s) of Alzheimer’s and dementia and any behavioral disturbances is required to properly code to the highest level of specificity. And again, proper coding will ultimately provide better data to researchers and in the end serve the greater good.

So for those providers who ask, “What’s in it for me to document all the new data elements required in ICD-10?” remember that it could be you or a loved one who may ultimately benefit tomorrow from the data we capture today. 

About the Author

Kathy Pride, CPC, RHIT, CCS-P, is vice president of professional services for Panacea Healthcare Solutions. Kathy has extensive experience in management, project implementation, coding, billing, physician documentation improvement, compliance audits and education. She is also an approved ICD-10 Trainer through the American Health Information Management Association (AHIMA) and a previous member of the AAPC National Advisory Board (1998 – 2000).

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Kathy Pride, CPC, RHIT, CCS-P, AHIMA-Approved ICD-10-CM/PCS Trainer

Kathy is a proven leader in healthcare revenue cycle management with extensive experience in management, project implementation, coding, billing, physician documentation improvement, compliance audits, and education. She has trained and managed Health Information Management (HIM) professionals in multiple environments. She is currently the Senior Vice President of Coding and Documentation Services for Panacea Healthcare Solutions. Kathy has provided compliance auditing and documentation education to hundreds of physicians and coders throughout her career.