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ICD-10 Guide
DiagnosesAgitated Dementia

Agitated Dementia

ICD-10 Coding for Agitated Dementia(F02.B11, G30.1)

PRIMARY SPECIALTYNeurology
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Agitated Dementia?
Essential facts and insights about Agitated Dementia

Key Clinical Considerations:

  • Presence of cognitive decline affecting daily functioning, with agitation as a prominent symptom.
  • No specific laboratory findings; however, tests may be conducted to rule out other causes of dementia.
  • Physical examination may reveal signs of agitation, restlessness, and possible aggression.
  • Imaging studies such as MRI or CT may show atrophy in specific brain regions associated with dementia.
  • Severity can be assessed using scales such as the Clinical Dementia Rating (CDR) or the Neuropsychiatric Inventory (NPI) to evaluate agitation.

Clinical Information

Clinical Criteria & Documentation Requirements

  • Document the patient's cognitive status, behavioral symptoms, and any functional impairments.
  • Use specific terminology such as 'agitated behavior' or 'cognitive decline' in the medical record.
  • Examples include: 'Patient exhibits significant agitation and confusion, impacting daily activities.'
  • Medical necessity must be established through documentation of the impact of symptoms on the patient's quality of life.
  • Quality measures may include assessments of agitation and cognitive function over time.

Coding Guidelines

Usage Guidelines & Examples

  • Use F02.B11 for agitated dementia when agitation is a prominent feature of the dementia diagnosis.
  • Do not use this code if the agitation is due to a primary psychiatric disorder or another type of dementia without agitation.
  • Compare with G30.1 (Alzheimer's disease with behavioral disturbance) for similar presentations but different underlying causes.
  • Common errors include misclassifying agitation as a primary psychiatric disorder rather than a symptom of dementia.
  • In complex cases, consider the primary cause of dementia and the presence of agitation when selecting codes.

Code Exclusions

Important Exclusions

  • Excludes primary psychiatric disorders such as schizophrenia or bipolar disorder with agitation.
  • Alternative codes for excluded conditions may include F20 (Schizophrenia) or F31 (Bipolar disorder).
  • Conditions are excluded because agitation may not be related to dementia but rather to a primary psychiatric issue.
  • Common mistakes include coding agitation without confirming the underlying cause as dementia.
  • Related but distinct conditions include frontotemporal dementia and Lewy body dementia, which may present differently.

Related ICD-10 Codes

Primary Codes
F02.B11
Agitated dementia due to other specified dementia
G30.1
Alzheimer's disease with behavioral disturbance
Ancillary Codes
Z91.83
Differential Codes
R45.1
R45.1
when agitation is not linked to dementia.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Neurology

Specialty Applications

  • Applies to patients diagnosed with dementia exhibiting significant agitation.
  • Common in older adults, particularly those with Alzheimer's disease or vascular dementia.
  • Clinical settings include inpatient psychiatric units, outpatient neurology clinics, and emergency departments.
  • Specialty-specific applications are relevant in neurology, geriatrics, and psychiatry.
  • Treatment contexts include pharmacological management of agitation and behavioral interventions.

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Template 1

Template: 'Patient diagnosed with agitated dementia based on cognitive decline and agitation symptoms.'

Template 2

Template: 'Clinical presentation consistent with agitated dementia including significant agitation and confusion.'

Template 3

Template: 'Diagnostic criteria for agitated dementia met as evidenced by agitation impacting daily activities.'

Template 4

Template: 'Treatment plan initiated for agitated dementia with pharmacological and behavioral interventions.'

Template 5

Template: 'Follow-up care for agitated dementia including monitoring of agitation levels and cognitive function.'

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

What documentation is required for this diagnosis?

Detailed documentation of cognitive decline, agitation symptoms, and their impact on daily life.

How does this differ from similar diagnoses?

Agitated dementia specifically includes agitation as a significant symptom, unlike other dementia types.

What are common billing considerations?

Ensure documentation supports the diagnosis and reflects the medical necessity for treatment.

What procedures are typically associated?

Related CPT codes may include 99406 (counseling for smoking cessation) and 96101 (psychological testing).

Are there any quality reporting implications?

Quality measures may include tracking agitation levels and cognitive assessments over time.