It is important when documenting dementia to state whether the patient’s current mental status is at their baseline or is acutely decompensated.
The patient’s baseline mental status should reflect the diagnosis of dementia as well as any behavioral deficiencies associated with dementia:
- Dementia with Behavioral Disturbance
- Wandering, aggressive behavior, combative behavior, violence, etc.
- Sundowning linked with Dementia
- Are there changes in the patient’s mental status at night?
Acute changes in mental status should be attributed to the causative condition, once identified. Typically, acute changes in mental status in patients with dementia are due to delirium or encephalopathy.
Documentation should clearly link both conditions to ensure proper coding.
- “Delirium superimposed on dementia”
- “Acute toxic encephalopathy on chronic dementia”
- “Metabolic encephalopathy associated with severe sepsis in the setting of dementia”
Download the complete tip, Dementia.