The choice of a treatment diagnosis is important for communication and focus of our interventions with persons who have cognitive impairments. As discussed in previous articles, indicating 'decreased function' alone does not fully describe the reason for skilled intervention. The International Classification of Diseases, Version 9 (ICD-9) continually refines and adds codes that describe conditions and complexities in order to support skilled intervention.
As discussed in the November 2005 article, we now have further opportunity to define therapy intervention for cognitive impairments with the addition of 2 ‘V' codes:
V15.88 History of fall, at risk for falling
V49.84 Bed confinement status
The Medicare B Cap and Exceptions process acknowledged Alzheimer's (331.0) as an automatic exception to the cap (Automatic meaning written requests do not have to be submitted for treatments beyond the $1,740 limit). The Exceptions process also acknowledged the Dementia codes (290.0 – 290.4) as complexities that may lengthen the course of treatment when coupled with other Medical and Treatment diagnosis (April 2006 article).
In some settings, medical diagnosis of the early stages of Alzheimer's or related Dementias may not yet be in a medical chart. Experienced therapists (such as those using the Allen battery) can identify and recognize the effect of a memory impairment on daily abilities and function. In those situations, 780.93, Memory Loss not specified elsewhere, is an excellent choice to further define our treatment interventions. 780.93 is also on the Medicare B Automatic Exceptions list.
As of October 1st, 2006, another supporting code has been added:
331.83: Mild Cognitive Impairment, so stated.
The National Center for Health Statistics (NCHS) presents the following description and parameters:
"Mild Cognitive Impairment (MCI) is a clinically identifiable precursor of dementia, particularly Alzheimer's disease (AD). Clinical criteria includes:
- Patient is not normal, but not demented.
- Evidence of cognitive deterioration for age
- Objective measured decline over time in cognitive task performance, and/or
- Subjective report of decline by patient and/or informant and objective cognitive deficits
- Preserved activities of daily living and minimal to no impairment on complex instrumental functions
Prevalence-population studies for those with MCI indicate 5% for age 60 and older, 15% for age 75 and older. MCI can progress to AD, vascular dementia, or Lewy Body Dementia. The initial neuropsychological impairments are verbal (word finding) and visual memory.
- MCI is not general dementia diagnosis (290.x) or Alzheimer's (331.0) since MCI has cognitive deficits but not impaired daily functions.
- MCI is not Memory Loss (780.93) since MCI does not have to be memory impairment.
The NCHS indicates that MCI has profound implications for the progression and likelihood of further memory or functional impairments. Thus the code 331.83 MCI was added to the 331.x series, Other cerebral degenerations. This series of ICD-9 codes (331.0 – 331.9) is presently listed as automatic exceptions to the Medicare B cap.
What does this mean for therapists?
- Who is allowed to determine Mild Cognitive Impairment?
The parameters of the code indicate that 'objective measured decline and objective cognitive deficits' must be present. It is preferable to have a physician indicate this condition. In some settings the physician relies on other health personnel to indicate conditions present in the patient. If in a formal evaluation, a Speech Pathologist or Occupational Therapist discovers such indicators as verbal (word finding) and visual memory deficits, that information should be brought to the attending physician and/or nurse manager for agreement and inclusion in the medical chart.
- Can this new diagnosis of MCI be used as a treatment diagnosis?
Yes, as an additional supporting diagnosis for treatment.
Examples:
Physical Therapy is treating someone for a gait disturbance, following a hip replacement. The person would be returning to an independent or ALF environment. If the diagnosis, MCI, is in the chart or determined through objective testing of a Speech Pathologist or Occupational Therapist, the addition of 331.83 (MCI) to 781.2, Abnormality of Gait or 719.7, Difficulty in Walking, present a support to discharge planning for safety and family training.
Occupational Therapy in the same scenario as above (hip replacement), would be treating self-care and home management for independent living. They may be seeing Muscle Weakness (728.87) or Lack of Coordination (781.3) as the person adapts to a weight shifting compensation. They may even start to determine a Memory Loss (780.93), even though MCI can be determined without a memory loss. If MCI is determined, it would be very important to address in regards to grocery shopping, communication of needs, phone skills, and visual memory in regards to safety.
Speech Language Pathologist again the same scenario, even though this is an orthopedic condition, the person is returning to independent living/ALF. Their safety and judgment is critical. Their reasoning and ability to adapt to new learning is essential for the future life style. If it is determined that this person has verbal (word finding) or visual memory deficits (MCI), it is essential that SLP be involved to either slow the progression and/or adapt the environment.
- For Speech Language Pathologists, how is this different from Symbolic Dysfunction (784.60)?
The addition or determination by an SLP that MCI is present supports the intervention for patients that might not normally have SLP treatment. 784.60 is often used when we have a ‘late effects of a CVA.' 784.60 can be coupled with MCI for persons who do not ‘score' at a symbolic dysfunction level.
- How do I know to look for MCI?
The interview/interpersonal and observation part of an evaluation will give you hints. When you ask a person about their life, they may talk ‘around' an answer. They may give you detailed descriptions of a person or event and not be able to ‘come to the point.' These slight signs may trip off an interdisciplinary request for an evaluation from SLP and/or OT. In addition, the therapist may administer the LACLS and the person may score in high level 4 or level 5.
- What Allen Cognitive Level (ACL) would this be most likely to show?
High 4, 4.6, or Level 5. That is the level in which a person can live independently. You may see such a person that does not have a Dementia Diagnosis (and you strongly suspect MCI) that is going to return to independent living/ALF. Your skills in discovering this communication (verbal, word finding) or visual memory loss (can't find my keys, purse, etc.) with or without a definite ‘memory loss,' is critical to providing safety tips, independent living skills, and slow possible progression to a more serious condition.
Summary: Remember MCI does not show with functional daily living skills. It is a serious precursor to Dementia and/or Alzheimer's. Skilled therapeutic evaluation and intervention can keep these persons safer for longer.
It is strongly advised to discuss your findings with the physician before including this MCI diagnosis in medical documentation.
Comments from Kim Warchol
I want to thank Mary for her diligence in finding this new code and in her quest to interpret how to apply this to our dementia therapy services.
I also want to bring up the point that there does not yet appear to be universal agreement on the definition of Mild Cognitive Impairment (MCI). Some definitions define MCI as not impacting IADLs and some indicate that the person might have some minimal impairment in IADLs. Therefore, we suggest that you can consider this code for a person functioning in a High Allen Level 4 or Allen Level 5.
However, because this term may be looked at as a diagnosis that could have significant implications, heed Mary's advice and make certain the patient's doctor is in agreement with this diagnostic code and that the doctor includes it on the person's diagnostic list.
A story to learn from:
I was referred to see a lady who was functioning at 4.8 and still living at home alone. During the initial discussion with the referring physician's nurse, she used the word "dementia" and I wrote it down. Although, the doctor had made the official diagnosis of MCI, not dementia.
I then went to evaluate and treat the patient and used the word dementia in conversation and again in her charting. This became a very serious problem as the patient threatened to sue me because I had "labeled her" inappropriately. After speaking with the doctor's office, I was advised to call the intermediary to inform them of my error and the patient's concern. The intermediary asked that I change my documentation to remove all of the dementia terms. This was both important to the lady personally and I was told that it could have a greater impact on her health care process.
I want to be sure that each of you understand the importance of using terminology such as this correctly. It is wonderful that we have been given the opportunity to demonstrate our expertise in the area of cognition, but we must be cautious. Therefore, our advice is to be sure to use your Allen battery tools, document these results, and obtain verbal and written agreement from the physician before using the MCI supporting code.