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ICD-10 Guide
ICD-10 CodesF03.9

F03.9

Billable

Unspecified dementia, unspecified severity

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 F03.9 is a billable code used to indicate a diagnosis of unspecified dementia, unspecified severity.

Key Diagnostic Point:

Unspecified dementia, unspecified severity (F03.9) is a diagnosis used when a patient exhibits symptoms of dementia that cannot be classified into a specific type or severity level. Dementia is a general term for a decline in cognitive function that interferes with daily life and activities. It encompasses various types, including Alzheimer's disease, vascular dementia, Lewy body dementia, and frontotemporal dementia. Patients may present with memory loss, impaired reasoning, and changes in behavior or personality. Cognitive assessments, such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA), are often utilized to evaluate the extent of cognitive impairment. Behavioral symptoms may include agitation, depression, anxiety, and social withdrawal, which can complicate the clinical picture. Caregiver support is crucial, as caregivers often face significant emotional and physical challenges while managing the care of individuals with dementia. This code is typically used when the clinician has not specified the type of dementia or when the severity of the condition is not clearly defined, necessitating careful documentation to support the diagnosis.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in dementia types and symptoms
  • Need for comprehensive cognitive assessment documentation
  • Potential overlap with other neurocognitive disorders
  • Subjectivity in determining severity

Audit Risk Factors

  • Insufficient documentation of cognitive assessments
  • Lack of clarity in behavioral symptom descriptions
  • Inadequate justification for unspecified severity
  • Failure to document caregiver support and involvement

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed cognitive assessments, history of present illness, and behavioral symptom documentation.

Common Clinical Scenarios

Patients presenting with memory loss, confusion, and changes in behavior without a clear diagnosis.

Billing Considerations

Ensure thorough documentation of cognitive tests and any referrals to specialists.

Geriatrics

Documentation Requirements

Comprehensive geriatric assessments, including functional status and caregiver support.

Common Clinical Scenarios

Older adults with cognitive decline and behavioral changes, often in the context of multiple comorbidities.

Billing Considerations

Focus on the impact of dementia on daily living and the need for caregiver resources.

Coding Guidelines

Inclusion Criteria

Use F03.9 When
  • According to ICD
  • 10 coding guidelines, F03
  • 9 should be used when the type of dementia is not specified
  • Coders must ensure that documentation supports the diagnosis and that any cognitive assessments performed are recorded

Exclusion Criteria

Do NOT use F03.9 When
  • Exclusion criteria include cases where a specific type of dementia is diagnosed

Related ICD-10 Codes

Related CPT Codes

96116CPT Code

Neuropsychological testing

Clinical Scenario

Used to assess cognitive function in patients suspected of having dementia.

Documentation Requirements

Document the specific tests performed and the results.

Specialty Considerations

Neurologists should ensure that the testing aligns with the patient's clinical presentation.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of dementia types, but F03.9 remains a necessary code for cases where the type is not specified. It emphasizes the importance of thorough documentation to support the diagnosis.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of dementia types, but F03.9 remains a necessary code for cases where the type is not specified. It emphasizes the importance of thorough documentation to support the diagnosis.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of dementia types, but F03.9 remains a necessary code for cases where the type is not specified. It emphasizes the importance of thorough documentation to support the diagnosis.

Resources

Clinical References

  • •
    Alzheimer's Association

Coding & Billing References

  • •
    Alzheimer's Association

Frequently Asked Questions

When should I use F03.9?

Use F03.9 when a patient exhibits symptoms of dementia, but the specific type or severity has not been determined. Ensure that documentation supports the diagnosis.