Unspecified dementia, mild, with agitation

This code describes a patient experiencing a mild form of dementia that is not further specified as to type (e.g., Alzheimer's, vascular). A key component is the presence of agitation, which can manifest as restlessness, aggression, or disruptive behaviors. The "mild" specifier indicates that the cognitive decline is noticeable but does not significantly impair daily living activities.

Use this code when documentation clearly indicates a diagnosis of dementia of an unspecified type, the severity is explicitly stated as mild, and agitation is a documented symptom. This code is appropriate when the provider has not yet determined the specific etiology of the dementia but has identified its presence and associated behavioral disturbance.

• Ensure documentation specifies both the "mild" severity and the presence of "agitation" for accurate code assignment.
• Avoid using this code if the type of dementia is known (e.g., Alzheimer's, vascular); instead, code to the specific type with agitation.
• Always review the entire medical record for more specific information regarding the dementia type before defaulting to "unspecified."