F02.A11

Dementia in other diseases classified elsewhere, moderate, with agitation

F02.A11 is a terminal clinical diagnosis code used for patients experiencing dementia that is etiologically linked to underlying physiological conditions classified elsewhere, such as Parkinson's disease, Huntington's disease, or Lewy body disease. This specific code identifies the 'moderate' stage of cognitive decline, which is clinically defined by significant interference with independent living, requiring the patient to have assistance with some activities of daily living (ADLs) and most instrumental activities of daily living (IADLs). The diagnosis is further specified by the presence of agitation, which encompasses a spectrum of behaviors including physical restlessness, pacing, verbal aggression, or combativeness. As a manifestation code, F02.A11 must be preceded by the code for the underlying systemic or neurological condition causing the cognitive impairment.

Clinical Symptoms

  • Severe short-term memory loss
  • Disorientation to time, place, and person
  • Verbal aggression including yelling or shouting
  • Physical aggression or combativeness toward caregivers
  • Constant pacing or wandering
  • Akathisia or extreme physical restlessness
  • Resistance to personal care and hygiene tasks
  • Inability to perform complex tasks (IADLs)
  • Significant difficulty with dressing or grooming (ADLs)
  • Sundowning (increased agitation in late afternoon/evening)
  • Emotional lability and irritability
  • Repetitive vocalizations or questions
  • Paranoia or delusional thinking
  • Sleep-wake cycle disturbances

Common Causes

  • Parkinson's disease
  • Huntington's disease
  • Dementia with Lewy bodies
  • Frontotemporal lobar degeneration
  • HIV infection
  • Creutzfeldt-Jakob disease
  • Traumatic brain injury
  • Multiple sclerosis
  • Neurosyphilis
  • Prion diseases
  • Chronic traumatic encephalopathy

Documentation & Coding Tips

Explicitly identify and sequence the underlying physiological condition before the dementia code.

Example: Primary Diagnosis: G31.83 Dementia with Lewy bodies. Secondary Diagnosis: F02.A11 Dementia in other diseases classified elsewhere, moderate, with agitation. Clinical Note: Patient presents with progressive cognitive decline and visual hallucinations characteristic of Lewy Body disease. Current status is moderate severity as the patient requires significant assistance with instrumental activities of daily living (IADL) and some basic ADLs. Agitation is evidenced by frequent verbal outbursts and physical restlessness during evening hours.

Billing Focus: Ensure the primary etiology code is sequenced first to satisfy the code first instructional note in the ICD-10-CM Tabular List.

Define the moderate severity level by documenting the patient's functional limitations in ADLs.

Example: The patient is staged at moderate severity based on a FAST scale score of 5 and MoCA score of 12. Assessment: The patient is no longer able to manage medications or finances independently and requires supervision for dressing and hygiene. F02.A11 is selected to reflect this moderate functional impairment along with active agitation.

Billing Focus: Documentation must specify moderate to differentiate from mild (F02.9) or severe (F02.B) stages, impacting the DRG assignment in inpatient settings.

Document specific behavioral manifestations to justify the with agitation suffix.

Example: The patient exhibits daily episodes of physical agitation, including pacing and resistive behavior during morning cares. These symptoms are not better explained by an acute delirium (F05). Diagnosis: F02.A11 assigned due to persistent agitation requiring pharmacological intervention with low-dose quetiapine.

Billing Focus: Agitation must be explicitly documented to use the .A11 extension instead of .A0 (without behavioral disturbance).

Clarify the absence of delirium to ensure the agitation is a chronic manifestation of dementia.

Example: Patient seen for management of moderate dementia related to Parkinson's disease (G20.A1). Agitation is chronic and stable, not representing an acute change in mental status. Labs rule out UTI or metabolic causes for increased confusion. Continue F02.A11 for behavioral management in the setting of chronic neurodegeneration.

Billing Focus: Excluding F05 (Delirium) prevents billing conflicts and ensures the dementia diagnosis is the primary focus of the encounter.

Link the dementia and behavioral symptoms to the primary underlying disease using causal language.

Example: Dementia due to Parkinson's disease, currently moderate in severity. Patient presents with agitation manifested by combative behavior during bathing. Plan: Adjust carbidopa-levodopa and continue behavioral interventions. Code: G20.A1 followed by F02.A11.

Billing Focus: Use of terms like due to or associated with clarifies the clinical relationship for auditors.

Relevant CPT Codes

Related Diagnoses

Hierarchy