ICD code G31.84 is used to classify mild cognitive impairment when the cause is uncertain or unknown, aiding in consistent medical documentation.
ICD code G31.84 is used to identify a diagnosis of mild cognitive impairment where the cause is uncertain or unknown. This code is typically utilized in medical records to document cases where a patient exhibits cognitive decline that is noticeable but not severe enough to interfere significantly with daily life, and where the underlying cause of this impairment has not been determined.
1. Memory Complaints: The patient reports noticeable memory problems, such as forgetting recent events or conversations, which are not typical for their age.
2. Objective Memory Impairment: Clinical assessments and cognitive tests indicate measurable deficits in memory function, particularly in recalling recent information.
3. Preserved General Cognitive Function: Despite memory issues, the patient maintains overall cognitive abilities, including reasoning, language, and visuospatial skills, that are appropriate for their age and education level.
4. Intact Activities of Daily Living (ADLs): The patient is capable of performing daily activities independently, such as managing finances, cooking, and personal hygiene, without significant difficulty.
5. Absence of Dementia: The symptoms do not meet the criteria for dementia, as there is no significant impairment in social or occupational functioning.
6. Uncertain or Unknown Etiology: The cause of the cognitive impairment is not clearly identifiable, and there is no definitive diagnosis of a specific neurological or psychiatric disorder.
7. Gradual Onset and Progression: The cognitive decline has developed gradually over time, rather than suddenly, and may show a slow progression.
8. Exclusion of Other Causes: Other potential causes of cognitive impairment, such as depression, medication side effects, or acute medical conditions, have been ruled out through clinical evaluation.
For the ICD code G31.84, which pertains to mild cognitive impairment of uncertain or unknown etiology, the relevant CPT codes that may be applicable include:
1. 96116 - Neurobehavioral status exam (clinical assessment of thinking, reasoning, and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem-solving, and visual-spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report.
2. 96132 - Neuropsychological testing evaluation services by a physician or other qualified healthcare professional, first hour.
3. 96133 - Neuropsychological testing evaluation services by a physician or other qualified healthcare professional, each additional hour (List separately in addition to code for primary procedure).
4. 96138 - Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; first 30 minutes.
5. 96139 - Psychological or neuropsychological test administration and scoring by technician, two or more tests, any method; each additional 30 minutes (List separately in addition to code for primary procedure).
6. 96146 - Psychological or neuropsychological test administration, with single automated, standardized instrument via electronic platform, with automated result only.
These CPT codes are typically used in the evaluation and management of cognitive impairments and may be relevant for healthcare providers managing patients with the ICD code G31.84. It is important for providers to verify the specific services rendered and ensure proper documentation to support the use of these codes.
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