Vascular dementia, severe, with agitation

This code signifies a severe form of cognitive decline resulting from cerebrovascular disease, characterized by significant impairment in memory, executive function, and other cognitive domains. The patient also exhibits agitation, which is a behavioral and psychological symptom of dementia (BPSD).

Apply this code when documentation clearly indicates a diagnosis of vascular dementia that has progressed to a severe stage, impacting daily functioning and requiring substantial assistance. Crucially, the patient must also present with documented agitation as a current and significant symptom.

• Ensure the medical record explicitly states "severe" vascular dementia and "agitation" to support this specific code.
• Do not use this code if the dementia is mild or moderate, or if agitation is absent or attributed to another condition.
• Consider sequencing this code as the primary diagnosis if it is the main reason for the encounter, or as a secondary diagnosis if another condition is being primarily managed.