As a result of discussions at the September 2008 and March 2009 ICD-9-CM Coordination and Maintenance Committee meetings, new codes were released effective Oct. 1, 2010, for cognitive impairment. The proposal was initially jointly presented by the Department of Defense (DOD) and the Veteran’s Administration (VA) to better classify traumatic brain injury (TBI) and its effects. Previously, cognitive and memory conditions related to brain damage were coded in several places in ICD-9-CM, some of which had exclusions for brain damage and TBI. The new codes add specificity and are not specific to TBI; they may be assigned due to other organic brain damage and conditions classified elsewhere. These codes may be assigned as supplementary codes when the underlying cause is known, as well as before a more specific diagnosis is made.
Cognition may be defined to include “the discrimination between and selection of relevant information, acquisition of information, understanding and retention, and the expression and application of knowledge in the appropriate situation. Cognitive disability may be seen in reduced efficiency, pace and persistence of functioning, decreased effectiveness in the performance of routine activities of daily living (ADLs), or failure to adapt to novel or problematic situations.”
The term “cognitive deficits” is a general, inclusive term used to describe symptoms associated with a variety of thought processes, including perception, memory, learning, concentration, attention, communication and executive function. Multiple underlying conditions can cause cognitive deficits, including: metabolic disorders, poisoning, toxic exposures, neoplasm, circulatory disease (e.g., stroke), neurologic disease (e.g., multiple sclerosis), mental disorders (e.g., depression), adverse effects of medications, anoxia and TBI. The most common causes of cognitive impairments include senile or age-related decline (e.g., memory loss, dementia) and those due to TBI. Depending on the underlying cause, cognitive deficits may develop over variable time periods. Presentation varies in severity. Cognitive deficits may also be associated with speech and language impairments or disturbances in behavior or judgment. A patient may present for services to address cognitive deficit symptoms that may be related to a current disease or injury or due to sequelae from a previous old or healed injury. Treatment depends on diagnosis of an underlying cause.
Coding Tips
Coding guidelines allow the assignment of a symptom or condition code in conjunction with a late-effect code when reporting such symptoms due to previous injury. Assign the new subcategory 799.5 codes as appropriate, to report specific symptoms of organic cause in the absence of an underlying documented condition or when these symptoms are not routinely associated with a confirmed diagnosis. This subcategory excludes cognitive deficits associated with specific conditions, such as amnesia (780.93), cerebrovascular disease (438), and other cerebral degeneration or mild cognitive impairment, so stated (331.83). Refer to subcategory 799.5 and review the full list of excluded conditions.
Cognitive Impairment Codes
799.51 Attention or concentration deficit
This includes a deterioration in the patient’s abilities to focus on a task or concentrate at previous levels.
799.52 Cognitive communication deficit
This condition involves the breakdown of applied communication skills. Cognitive-communication assessment refers to appraisal of thought processes, including attention, orientation, organization/sequencing, recall and problem solving, insight, processing speed, and pragmatics.
799.53 Visuospatial deficit
The condition involves an inability or deterioration in the ability to comprehend and conceptualize visual representations and spatial relationships in learning and performing a task. The two components of visual processing are: locating an object in space (where?) and determining the identity of an object (what?).
799.54 Psychomotor deficit
This condition involves relating the psychologic processes associated with muscular movement to the production of voluntary movements. Examples include decreased rate of speech, decreased energy, decreased libido and anhedonia (an absence of pleasure from the performance of acts that would ordinarily be pleasurable).
799.55 Frontal lobe and executive function deficit
Executive function describes a set of cognitive abilities that control and regulate other abilities and behaviors and are necessary for goal-directed behavior. They include the ability to initiate and stop actions, to monitor and change behavior as needed, and to plan future behavior when faced with novel tasks and situations. Patients with this deficit are unable or hindered in their ability to anticipate outcomes and adapt to changing situations. The ability to form concepts and think abstractly is often affected.
799.59 Other signs and symptoms involving cognition
Disorders or symptoms that are not classified in any of the above sub-classifications should be reported with this code.
After review of the new codes and their associated inclusion and exclusion terms, test your knowledge with the following questions:
Questions
1. A patient who cannot place the numbers of a clock-face in the correct places may be said to suffer from which of the deficits below?
a. Frontal lobe and executive function deficit
b. Psychomotor deficit
c. Visuospatial deficit
d. None of the above
2. A deficit in the ability to recognize the significance of unexpected situations and to make alternative plans quickly when unusual events arise and interfere with normal routines involves which type of cognitive deficit?
a. Frontal lobe and executive function deficit
b. Psychomotor deficit
c. Visuospatial deficit
d. None of the above
3. The new codes in subcategory 799.5 may be assigned for all of the conditions listed below, except:
a. a patient with a previous TBI
b. a patient with documentation of visuospatial neglect
c. an Alzheimer’s patient with executive function deficits
d. codes from subcategory 799.5 may be assigned for all conditions listed above
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, facility solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.
Answers
1. c. An inability to place the numbers of a clock-face in the correct places demonstrates a deficit in locating an object in space, which is considered a visuospatial deficit.
2. a. Because the environment can be unpredictable, executive functions are important for successful adaptation and performance in real-life situations and allow people to initiate and complete tasks and to persevere in the face of challenges. Deficits in frontal lobe and executive function abilities hinder this type of adaptation.
3. b. Under subcategory 799.5, there is an excludes note for visuospatial neglect, which is assigned to code 781.8, Neurologic neglect syndrome. Neurologic neglect syndrome is a cluster of neurologic symptoms commonly found after right hemisphere damage.
