What is the ICD-10 (International Classification of Diseases, 10th Revision) code for an older adult patient with dementia without significant physical disturbances?

ICD-10 Code for Dementia Without Physical Disturbances

For dementia without behavioral disturbances or physical complications, use ICD-10 code F03.90 (Unspecified dementia without behavioral disturbance). 1, 2

Understanding the ICD-10 Coding Structure for Dementia

The ICD-10 classification system organizes dementia codes primarily in the F00-F03 series (mental and behavioral disorders) and the G30-G31 series (diseases of the nervous system). 1, 2

Key Code Categories:

• F03.90: Unspecified dementia without behavioral disturbance - This is the appropriate code when dementia is present without significant physical or behavioral complications 2

• F03.91: Unspecified dementia with behavioral disturbance - Used when behavioral or psychological symptoms of dementia (BPSD) are present 2

• F00-F02 series: Used for dementia with specified etiology (Alzheimer's disease, vascular dementia, etc.) when the underlying cause is documented 1, 2

Important Coding Considerations

When to Use F03.90 Specifically:

• The patient has documented cognitive decline meeting dementia criteria (impairment in at least two cognitive domains affecting daily function) 1
• No significant behavioral disturbances are present (no agitation, aggression, wandering, psychosis) 3
• No acute physical complications directly attributable to dementia are documented 2

Common Pitfall - Undercoding:

Dementia is significantly undercoded in clinical practice, with studies showing only 13% of patients receiving dementia medications had dementia listed as the primary diagnosis. 2 This occurs because:

• Clinicians focus on the acute presenting problem rather than the underlying dementia 2
• The ICD-10 system has limited clinical modification codes for dementia complications 2
• Dementia codes in the 290-331 series may be reimbursed at lower rates by some payers 2

Etiology-Specific Coding:

When the dementia etiology is known, use dual coding for more accurate documentation: 2

• G30.9 + F02.80: Alzheimer's disease without behavioral disturbance
• F01.50: Vascular dementia without behavioral disturbance
• G31.83 + F02.80: Dementia with Lewy bodies without behavioral disturbance

The etiology code (G-series) should be listed first, followed by the manifestation code (F-series). 2

Diagnostic Criteria Alignment

The ICD-10 definition requires: 1, 4

• Decline in memory AND other cognitive abilities (such as judgment, thinking, or planning) 1
• Sufficient severity to interfere with personal activities of daily living 1
• Symptoms present for at least 6 months in ICD-10 (though this duration requirement was removed in ICD-11) 1

Critical distinction: ICD-10 criteria can identify fewer cases of dementia compared to DSM-IV criteria (3.1% vs 29.1% prevalence in one study), primarily due to stricter memory impairment requirements. 5 However, when interpreted correctly—where "decline in other cognitive abilities such as abstraction, judgment, problem solving" means ANY of these functions rather than ALL—ICD-10 and DSM-IV show 100% agreement. 4

Documentation Requirements:

To support F03.90 coding, medical records should document: 2

• Specific cognitive domains impaired (memory, executive function, language, visuospatial, etc.) 3
• Impact on instrumental or basic activities of daily living 1
• Absence of behavioral disturbances (explicitly state "no agitation, aggression, or psychosis") 3
• Results of cognitive screening tools (MMSE, MoCA) if performed 3