Understanding ICD-10 Code F01.51: Vascular Disturbance With Behavioral Disturbance

The International Classification of Diseases (ICD) is a system used to record, classify, and keep statistics on diseases on a global basis. Its purpose is to provide a uniform system for the collection, processing, and classification of disease trends. It is also the standard used for insurance billing purposes. 

ICD Code Updates and Use

The ICD codes are updated regularly to include new information or new diseases that have been discovered. This year, the Centers for Medicare & Medicaid Services (CMS) has announced that from April 2023 on, updates will occur twice per year. With each update, codes are deleted, added, and clarified. The ICD-10 now includes a “New Technology” section. The ICD codes are updated frequently but undergo major changes less frequently. ICD-10 went into effect in 2015, but the new ICD-11 went into effect in 2022. 

Even though the ICD itself is updated less frequently, not every facility updates its systems to keep up. Government and public health agencies use the most recent codes, but many smaller facilities and insurance providers continue to use the old codes because it is not practical to update their systems that often. ICD-10 is still in use and will continue to be used by healthcare facilities for some time into the future. 

Understanding ICD-10 codes is important to clinical practice because it is important for insurance billing. It also helps provide clarity in the diagnosis and classification of a client’s condition. Understanding the ICD-10 codes and how to differentiate them from related codes helps get your clients the treatment they need and speeds insurance and third-party payer approval. It also clarifies communication between healthcare providers who are working as part of a person’s care team. 

ICD-10 Code F01.51 Vascular Dementia With Behavioral Disturbance

The ICD-10 code F01.51 is for vascular dementia with behavioral disturbance. Vascular dementia is dementia that occurs after a stroke or other disruption to the blood supply to the brain. This is the second most common form of dementia and accounts for as many as 15-20% of all dementia cases in the United States. 

Dementia is divided into four types with vascular dementia being one of the four. The others include: 

  • Alzheimer’s disease
  • Lewy body dementia
  • Pick’s disease (Frontotemporal Degeneration – FTD)

These diseases would typically fall under other related ICD-10 categories: 

  • F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
  • F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
  • F03.90 Unspecified dementia without behavioral disturbance
  • F03.91 Unspecified dementia with behavioral disturbance

All of these dementia-related codes have a component without behavioral disturbances or with behavioral disturbances. Codes with behavioral disturbances are of greatest concern for mental health and social work professionals. This article will delve deeper into vascular dementia with behavioral concerns present. 

What Is Vascular Dementia?

Vascular dementia is also called multi-infarct dementia. It is often difficult to diagnose and is less commonly known than other types of dementia, even though it is one of the more common forms of dementia. Vascular dementia occurs when a part of the brain does not get the oxygen and nutrients that it needs. This is usually because of damage to one or more blood vessels in the brain. 

From a diagnostic and coding standpoint, the issue becomes complicated because someone can have vascular dementia and another form of dementia at the same time. Vascular dementia can be primary or secondary to other forms of dementia. It usually requires medical tests to determine how much of a role each form of dementia plays. Either way, the presence of other forms of dementia can complicate treatment. 

Vascular dementia can occur as a result of a major stroke or through a series of minor strokes that might go unnoticed. These silent strokes only become apparent when they build up to the point that the impact leads to noticeable symptoms. Vascular dementia can be compounded by or be a factor in other forms of dementia, like Alzheimer’s and Lewy body dementia. 

Diagnosing Vascular Dementia With Behavioral Disturbance

Differential diagnosis between vascular dementia and other forms of dementia is important for vascular dementia with behavioral disturbance to avoid any delays in getting treatment started. The diagnosis process for this condition typically begins with the primary healthcare provider. The client might present with symptoms, such as: 

  • Short-term memory problems
  • Getting lost often
  • Crying or laughing inappropriately
  • Problems concentrating
  • Difficulty following instructions
  • Hallucinations
  • Loss of bowel or bladder control 

Other symptoms can also include: 

  • Problems with balance or walking
  • Depression 
  • Irritability
  • Personality changes
  • Tremors or reduced fine motor control

From a mental health standpoint, diagnosis, ongoing evaluation, and treatment will typically be in conjunction with a team of healthcare professionals or at least the person’s primary healthcare provider. Diagnosis will typically involve tests by a primary care or other specialist that include: 

  • Blood tests to measure brain function and rule out other causes
  • Brain imaging using CT or MRI
  • Neuropsychological testing
  • Psychiatric evaluation 
  • Psychological evaluation

Treatment and Prognosis

Unfortunately, once the brain damage has occurred, there is nothing that can be done to repair it. Treatment is directed toward managing symptoms and slowing down the progression of the disease by taking measures to prevent further damage. These treatments might include medication to treat the underlying causes of vascular dementia, medications to improve thinking, and medications to help with depression and psychological issues. Lifestyle changes to manage risk factors are also part of the typical treatment plan. In some cases, surgery such as angioplasty, stenting, and procedures to remove plaque from the carotid artery are needed to prevent further damage. 

The prognosis for those with vascular dementia depends on the amount of damage that has already occurred and which brain structures are affected. Physical and occupational therapy can help the person regain some or all of their function over time. Speech therapy can help with learning how to compensate for any communication impairment. Counselors and support groups play an important role in helping manage the emotional and behavioral effects of vascular dementia. 

Final Notes on Vascular Dementia

One of the most important differences between vascular dementia and other forms of dementia is that with lifestyle change and proper monitoring, it can be prevented for the most part. Managing major risk factors plays a key role in preventing vascular dementia and keeping it from getting worse once it has been diagnosed. As a mental health professional, you can play an important role in helping the client manage behavioral and emotional issues. You can also help support healthy lifestyle choices to help the person retain their present level of functioning or even improve over time. 

Controlling risk factors for stroke and heart disease is one of the most important supports to help the person stay as healthy as possible. Some of these healthy lifestyle changes for a person with vascular dementia are: 

  • Managing blood pressure
  • Managing cholesterol levels
  • Managing blood sugar levels
  • Eating a healthy diet
  • Quitting smoking
  • Cutting back on alcohol consumption 
  • Managing stress
  • Following medication and other prescribed treatments 

Vascular dementia may worsen over time, especially if contributing factors are allowed to go unchecked. Each person with vascular dementia is different and will be affected in a unique way. Treatments and lifestyle changes might slow the disease, and as part of the person’s healthcare team, someone with this disease can live a long and healthy life. 

How AutoNotes Can Help

When a person comes to you with vascular dementia, it will more than likely come as a referral from a primary care or other specialist. The client will usually already have an ICD-10 code F01.51 diagnosis with supporting clinical tests. The emotional and behavioral changes that can be associated with this disease often lead to referral to a mental health professional. 

As a clinician, one of your jobs will be to determine if all the emotional and behavioral issues are a result of vascular dementia or if the person has additional diagnoses. Throughout the treatment process, you will probably be working closely with other professionals on the care team. Tracking the primary and accompanying diagnoses is important to make sure the person receives timely and appropriate care. 

The key to providing appropriate client care is taking good notes and documenting progress. Insurance companies and third-party providers often need to see specific language and will deny treatment without them. AutoNotes can help make notetaking, SOAP Notes, and diagnostic notes easy. You can keep them all in one place and generate reports to share with other professionals quickly. 

AutoNotes is a powerful piece of software that can help you generate progress notes, DAP notes, and treatment plans quickly and easily. The system is secure, encrypted, and HIPAA-compliant. Personally identifiable information is easily hidden from view. AutoNotes has developed a set of templates that helps you make sure you do not miss essential information. You can use our AI tools to quickly summarize your session from various note formats, including BIRP and GIRP. It also lets you edit and download complete clinical notes, including a Mental Status Exam (MSE) in just a few clicks. 

AutoNotes can save you many hours of time spent on documentation in a single day. Its tracking system helps you improve coordination with other professionals, which means better client care. It also makes submitting insurance claims and documenting medical necessities easier, too. This means your clients can get the help they need quickly so they can get on with living the best life possible. Contact us to get started and see what AutoNotes can do.