Neurocognitive Disorders • With other behavioral or psychological disturbance: If the cognitive disturbance is accompanied by other clinically significant behavioral or psychological disturbance (e.g., apathy, aggression, disinhibition, disruptive behaviors or vocalizations, sleep or appetite/eating disturbance). • Without accompanying behavioral or psychological disturbance: If the cognitive disturbance is not accompanied by any clinically significant behavioral or psychological disturbance. Coding and Recording Procedures The following are examples of coding and recording different types of major NCDs. In cases where there is more than one type of associated behavioral or psychological disturbance, each is coded separately. (For more information, see coding table on pp. 682–683 and coding notes in the specific diagnostic criteria for each major and mild NCD subtype): • • • • Major neurocognitive disorder due to probable Alzheimer’s disease, mild, with anxiety: G30.9 Alzheimer’s disease, F02.A4 major neurocognitive disorder due to probable Alzheimer’s disease, mild, with anxiety. Major neurocognitive disorder due to possible Alzheimer’s disease, moderate, with mood symptoms: F03.B3 major neurocognitive disorder due to possible Alzheimer’s disease, moderate, with mood symptoms. Major neurocognitive disorder due to traumatic brain injury, moderate, with psychotic disturbance and agitation: S06.2XAS diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela; F02.B2 major neurocognitive disorder due to traumatic brain injury, moderate, with psychotic disturbance; F02.B11 major neurocognitive disorder due to traumatic brain injury, moderate, with agitation. Major neurocognitive disorder due to unknown etiology, severe, with mood symptoms: F03.C3 major neurocognitive disorder due to unknown etiology, severe, with mood symptoms. Mild Neurocognitive Disorder Diagnostic Criteria [diagnostic criteria unchanged] Specify whether due to: Note: Each subtype listed has specific diagnostic criteria and corresponding text, which follow the general discussion of major and mild neurocognitive disorders (NCDs). • Alzheimer’s disease • Frontotemporal degeneration • Lewy body disease • Vascular disease • Traumatic brain injury • Substance/medication use • HIV infection • Prion disease • Parkinson’s disease • Huntington’s disease • Another medical condition • Multiple etiologies • Unknown etiology Coding note: Code based on medical or substance etiology. An additional code indicating the etiological medical condition must immediately precede the diagnostic code F06.7z for mild NCD due to a medical etiology. An additional code is not used for medical etiologies that are judged to be “possible” (i.e., mild NCD due to possible Alzheimer’s Copyright 2022 American Psychiatric Association. All rights reserved.
13 disease, due to possible frontotemporal degeneration, due to possible Lewy body disease, possibly due to vascular disease, possibly due to Parkinson’s disease). See coding table on pp. 682–683. For substance/medication-induced mild NCD, code based on type of substance; see “Substance/Medication-Induced Major or Mild Neurocognitive Disorder.” Note: G31.84 is used for mild NCD due to unknown etiology and for mild NCD due to a possible medical etiology (e.g., possible Alzheimer’s disease); no additional code for medical or substance etiology is used. Specify (see coding table for details): • Without behavioral disturbance: If the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance. • With behavioral disturbance (specify disturbance): If the cognitive disturbance is accompanied by a clinically significant behavioral disturbance (e.g., apathy, agitation, anxiety, mood symptoms, psychotic disturbance, or other behavioral symptoms). Coding note: Use additional disorder code(s) to indicate clinically significant psychiatric symptoms due to the same medical condition causing the mild NCD (e.g., F06.2 psychotic disorder due to traumatic brain injury, with delusions; F06.32 depressive disorder due to HIV disease, with major depressive–like episode). Note: Mental disorders due to another medical condition are included with disorders with which they share phenomenology (e.g., for depressive disorders due to another medical condition, see the chapter “Depressive Disorders”). Coding and Recording Procedures The following are examples of coding and recording different types of mild NCDs. (For more information, see coding table on pp. 682–683 and coding notes in the specific diagnostic criteria for each major and mild NCD subtype): • • • Mild neurocognitive disorder due to probable Alzheimer’s disease, without behavioral disturbance: G30.9 Alzheimer’s disease, F06.70 mild neurocognitive disorder due to probable Alzheimer’s disease, without behavioral disturbance. Mild neurocognitive disorder due to possible Alzheimer’s disease, without behavioral disturbance: G31.84 mild neurocognitive disorder due to possible Alzheimer’s disease, without behavioral disturbance. Mild neurocognitive disorder due to traumatic brain injury, with behavioral disturbance: S06.2XAS diffuse traumatic brain injury with loss of consciousness of unspecified duration, sequela; F06.71 mild neurocognitive disorder due to traumatic brain injury, with behavioral disturbance [with the disturbance being depression]; F06.31 depressive disorder due to traumatic brain injury, with depressive features. Copyright 2022 American Psychiatric Association. All rights reserved.
Neurocognitive Disorders Associated etiological medical code for major or mild neurocognitive disorder (NCD) Major NCD code Mild NCD code Alzheimer’s disease, probable G30.9a F02.xyb,c F06.7zd Alzheimer’s disease, possible No additional medical code F03.xyb,c G31.84 Frontotemporal degeneration, probable G31.09a F02.xyb,c F06.7zd Frontotemporal degeneration, possible No additional medical code F03.xyb,c G31.84 Lewy body disease, probable G31.83a F02.xyb,c F06.7zd Lewy body disease, possible No additional medical code F03.xyb,c G31.84 Vascular disease, probably due to I67.9 (applies only to mild vascular NCD) F01.xyb,c Do not use additional medical code. F06.7zd Vascular disease, possibly due to No additional medical code F03.xyb,c G31.84 Traumatic brain injury S06.2XASa F02.xyb,c F06.7zd Substance/ medicationinduced No additional medical code Code based on the type of substance causing the major NCD.e,f,g Code based on the type of substance causing the mild NCD.e,g HIV infection B20a F02.xyb,c F06.7zd Prion disease A81.9a F02.xyb,c F06.7zd Parkinson’s disease, probably due to G20a F02.xyb,c F06.7zd Parkinson’s disease, possibly due to No additional medical code F03.xyb,c G31.84 Huntington’s disease G10a F02.xyb,c F06.7zd Due to another medical condition Code the other medical condition first (e.g., G35 multiple sclerosis). F02.xyb,c F06.7zd Etiological subtype Copyright 2022 American Psychiatric Association. All rights reserved.
Major and Mild Neurocognitive Disorders Associated etiological medical code for major or mild neurocognitive disorder (NCD) Etiological subtype Major NCD code Mild NCD code Due to multiple etiologies Code all of the etiological medical conditions first. If vascular disease is contributing to the mild NCD, code I67.9 (cerebrovascular disease) along with the other etiological medical conditions; I67.9 is not used for major vascular NCD. F02.xyb,c (code once for major NCD due to all etiologies that apply) Code also F01.xyb,c for major NCD probably due to vascular disease if present. Code also the relevant substance/ medicationinduced major NCDs if substances or medications play a role in the etiology. F06.7zd (code once for mild NCD due to all etiologies that apply, including mild NCD probably due to vascular disease if present) Code also the relevant substance/ medicationinduced mild NCDs if substances or medications play a role in the etiology. Due to unknown etiology No additional medical code F03.xyb,c G31.84 Note: Footnotes a–d do not apply to substance/medication-induced NCD. aCode etiological medical condition first (i.e., before the code for major or mild NCD). b Major NCD: Next code severity (4th character [placeholder “x” in table]) as follows: .Ay mild, .By moderate, .Cy severe. (“y” is placeholder for accompanying behavioral or psychological disturbance, described in footnote c below.) cMajor NCD: Then code any accompanying behavioral or psychological disturbance (5th and 6th characters [placeholder “y” in table]): .x11 with agitation; .x4 with anxiety; .x3 with mood symptoms; .x2 with psychotic disturbance; .x18 with other behavioral or psychological disturbance (e.g., apathy); .x0 without accompanying behavioral or psychological disturbance. d Mild NCD: Code based on accompanying behavioral disturbance, if any (5th character [placeholder “z” in table]) either F06.70 without behavioral disturbance or F06.71 with behavioral disturbance (e.g., apathy, agitation, anxiety, mood symptoms, psychotic disturbance, or other behavioral symptoms). e See coding table in “Substance/Medication-Induced Major or Mild Neurocognitive Disorder” for ICD10-CM code. fThe severity specifiers “mild,” “moderate,” and “severe” cannot be coded but should still be recorded for substance/medication-induced major NCD. gThe accompanying symptom specifiers “With agitation,” “With anxiety,” “With mood symptoms,” “With psychotic disturbance,” “With other behavioral or psychological disturbance,” and “Without accompanying behavioral or psychological disturbance” cannot be coded but should still be recorded. Coding note: For major NCDs due to [medical etiology] and probable (including “probably due to”) etiologies, when multiple clinically significant behavioral and psychological disturbances occur, multiple ICD-10-CM codes are needed. For example, for major NCD due to probable Alzheimer’s disease, severe, accompanied by agitation, delusions, and depression, four codes are needed: G30.9 Alzheimer’s disease; F02.C11 (with agitation); F02.C2 (with psychotic disturbance); and F02.C3 (with mood symptoms). For major NCDs due to unknown etiology and possible (including “possibly due to”) etiologies, when multiple clinically significant behavioral and psychological disturbances occur, multiple ICD-10-CM codes are needed. For example, for major NCD due to possible Alzheimer’s disease, severe, accompanied by agitation, delusions, and depression, three codes are needed: F03.C11 (with agitation); F03.C2 (with psychotic disturbance); and F03.C3 (with mood symptoms). Copyright 2022 American Psychiatric Association. All rights reserved.
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