F03.90

Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety

Unspecified dementia (F03.90) is a clinical syndrome characterized by a significant decline from a previous level of cognitive performance in one or more domains, including learning and memory, language, executive function, complex attention, perceptual-motor skills, or social cognition. The 'unspecified' designation is used in clinical documentation when the specific underlying etiology—such as Alzheimer's disease, vascular disease, Frontotemporal lobar degeneration, or Lewy body disease—is not identified, documented, or is unknown at the time of the encounter. The 'unspecified severity' denotes that the stage of the disease (mild, moderate, or severe) is not stated. Crucially, the .90 suffix indicates the absence of clinically significant behavioral or psychological symptoms of dementia (BPSD), such as agitation, aggression, hallucinations, delusions, or mood disturbances, which often complicate the management of dementing illnesses.

Clinical Symptoms

Short-term memory impairment
Difficulty with executive functioning and complex tasks
Word-finding difficulties (anomia)
Disorientation to time or place
Impaired abstract reasoning
Misplacing items frequently
Difficulty performing activities of daily living (ADLs)
Subtle personality changes
Reduced concentration and attention span
Agnosia (failure to recognize objects or people)
Apraxia (impaired ability to carry out motor activities despite intact motor function)

Common Causes

Neurodegenerative processes (e.g., incipient Alzheimer's or Frontotemporal dementia)
Chronic cerebrovascular disease
Metabolic encephalopathy
Vitamin B12 or folate deficiency
Hypothyroidism
Chronic infection (e.g., Neurosyphilis, HIV-associated neurocognitive disorder)
Traumatic brain injury (TBI) history
Chronic alcohol or substance use
Normal pressure hydrocephalus

Documentation & Coding Tips

Document the absence of behavioral and psychological symptoms of dementia to support the use of the 0 suffix.

Example: Patient presents for follow-up of chronic cognitive decline. History obtained from daughter reveals no evidence of agitation, aggression, or wandering. Review of systems is negative for hallucinations or delusions. Diagnosis: Unspecified dementia, unspecified severity, without behavioral disturbance (F03.90). This supports the HCC 52 risk adjustment category for chronic cognitive failure.

Billing Focus: Documentation must explicitly state the absence of behavioral disturbances such as agitation, wandering, or combativeness to justify the F03.90 code over F03.91.

Specify that the dementia etiology is currently under investigation or remains unknown to justify the use of the F03 unspecified category.

Example: 78-year-old male with progressive memory loss over 12 months. Neuroimaging shows generalized atrophy but no clear vascular pattern. Patient does not meet full criteria for Alzheimer's or Lewy Body at this time. Assessment: Unspecified dementia, unspecified severity, without behavioral disturbance. Plan: Refer to neurology for PET scan and formal neuropsychological testing.

Billing Focus: The documentation of unknown etiology justifies the unspecified ICD-10 code while clinical workup is pending, preventing premature coding of specific diseases like Alzheimer's.

Incorporate a standardized cognitive assessment tool to establish the baseline and severity, even if the code remains unspecified.

Example: Patient scored 18/30 on the Montreal Cognitive Assessment (MoCA), indicating significant impairment. No mood or psychotic symptoms noted during the 35-minute encounter. Assessment: Unspecified dementia, unspecified severity, without behavioral disturbance. We will monitor for progression into moderate or severe stages.

Billing Focus: Quantitative data from tools like the MMSE or MoCA supports the medical necessity of E/M levels and helps define severity for future code specificity.

Link the dementia diagnosis to its impact on activities of daily living to demonstrate clinical complexity.

Example: The patient's unspecified dementia now requires 24-hour supervision. They are unable to manage medications or finances independently. No behavioral issues or psychotic symptoms are present. Encounter involved 32 minutes of total time. Assessment: Unspecified dementia, unspecified severity, without behavioral disturbance (F03.90).

Billing Focus: Documenting functional limitations justifies a higher complexity of Medical Decision Making (MDM) for E/M codes like 99214.

Explicitly mention the absence of anxiety or mood disturbances to differentiate from specific mood-related dementia codes.

Example: Patient remains oriented only to person. No signs of depression, anxiety, or social withdrawal were observed. The patient is calm and cooperative during the examination. Diagnosis: Unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, or anxiety.

Billing Focus: Excluding mood disturbances prevents the incorrect application of codes from the F01-F03 blocks that imply psychiatric comorbidities.

Relevant CPT Codes

99214 - Office or other outpatient visit for the evaluation and management of an established patient, moderate level of medical decision making
Commonly used for dementia follow-ups where multiple medications are reviewed and functional decline is managed.
99213 - Office or other outpatient visit for the evaluation and management of an established patient, low level of medical decision making
Used for stable dementia patients during routine check-ups with minimal management changes.
99483 - Cognitive assessment and care plan services for a patient with cognitive impairment
The gold standard for the initial thorough workup of unspecified dementia to establish a care strategy.
96127 - Brief emotional/behavioral assessment
Used to screen for the absence of behavioral or mood disturbances to support the F03.90 diagnosis.
99204 - Office or other outpatient visit for the evaluation and management of a new patient, moderate level of medical decision making
Applied during the initial diagnostic visit when a patient first presents with symptoms of dementia.
96116 - Neurobehavioral status exam
Provides objective clinical data to support the diagnosis of unspecified dementia.
99497 - Advance care planning
Essential for dementia patients to discuss future care preferences while they still have capacity.
99308 - Subsequent nursing facility care, moderate level of medical decision making
Used for managing dementia patients in long-term care settings when clinical issues arise.
99442 - Telephone evaluation and management service, 11-20 minutes
Frequent for coordinating care with family members of dementia patients regarding medication or safety.
G0506 - Comprehensive assessment of and care planning for patients requiring chronic care management services
Dementia often qualifies for chronic care management due to its long-term impact on health.