Unspecified dementia, moderate, with agitation

This code signifies a diagnosis of dementia of an unspecified type, presenting with moderate cognitive decline and behavioral disturbances characterized by agitation. Agitation in this context refers to excessive motor activity, restlessness, or verbal outbursts. The "unspecified" nature indicates that the underlying cause of the dementia has not been determined or documented.

This code is appropriate when a patient's medical record clearly documents a diagnosis of dementia, the severity is assessed as moderate, and agitation is a prominent symptom. Documentation should explicitly state "moderate dementia with agitation" without specifying the type of dementia (e.g., Alzheimer's, vascular). It is used when the physician has not identified a specific etiology for the dementia.

• Ensure the documentation explicitly states "moderate" severity and the presence of "agitation."
• Do not use this code if a specific type of dementia (e.g., Alzheimer's, vascular) is documented; instead, use the appropriate code from categories F00-F02.
• Sequence this code as the primary diagnosis if it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity impacting care.