Created Jun 2012
Reviewed Dec 2019
Updated Sep 2022
Query
Can agitation be coded separately to dementia?
Response
Based on clinical advice agitation is not an inevitable part of dementia. Agitation can be a sign that something else is going on (eg, stress, medical condition), and therefore the cause of the agitation should be coded as per ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses and not the agitation.
If there is clinical documentation linking the agitation to a mental health disorder (F00-F99), which meets ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses, follow the excludes note at block R40-R46 Symptoms and signs involving cognition, perception, emotional state and behaviour (Excludes: those constituting part of a pattern of mental disorder (F00–F99)) and just code the mental health disorder.
If however there is no identifiable cause for the agitation then R45.1 Restlessness and agitation may be coded if it meets the criteria in ACS 0001 Principal diagnosis or ACS 0002 Additional diagnoses ie, it is significant in its own right and treated independently (see Note at the beginning of Chapter 18 Symptoms, signs and abnormal clinical findings, not elsewhere classified).
See also Coding Rule Q3396 Behavioural and psychological symptoms of dementia (BPSD).