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Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training: Alzheimer's Disease


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Case Scenario 2-Home Health Skilled Nursing Care Teaching and Training: Alzheimer's Disease
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Going Beyond Diagnosis Case Scenario #2 Palmetto GBA

A physician has ordered skilled nursing care for teaching behavioral techniques to a care-giving niece of a patient with moderate Alzheimer’s disease to gain the patient’s cooperation during mealtime. Due to the patient’s wandering behaviors, she will not stay seated for a meal and the niece believes she is “trying to be difficult.” The patient has been gradually losing weight (10 pounds over 2 months) and she is less coordinated with her utensils due to her underlying dementia as well as a new onset tremor. The teaching services are reasonable and necessary for the patient’s treatment and adequate nutritional intake.

Description of scenario using ICD-10:

G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease
G30.9 Alzheimer's disease, unspecified (used as a secondary diagnosis)
R25.0 Abnormal head movements (used as a secondary diagnosis)
R25.1 Tremor, unspecified (used as a secondary diagnosis)
R25.2 Cramp and spasm (used as a secondary diagnosis)
R25.3 Fasciculation (used as a secondary diagnosis)
R25.8 Other abnormal involuntary movements (used as a secondary diagnosis)
R25.9 Unspecified abnormal involuntary movements (used as a secondary diagnosis)

Additional description of scenario using ICF:

ICF Component: Body Function and Structure

ICF Domain: Mental function

b117 – Intellectual functions – General mental functions, required to understand and constructively integrate the various mental functions, including all cognitive functions and their development over the life span.

Inclusions: functions of intellectual growth; intellectual retardation, mental retardation, dementia

ICF Domain: Functions of the digestive, metabolic, and endocrine systems

b530 – Weight maintenance functions – Functions of maintaining appropriate body weight, including weight gain during the developmental period.

Inclusions: functions of maintenance of acceptable Body Mass Index (BMI); and impairments such as underweight, cachexia, wasting, overweight, emaciation and such as in primary and secondary obesity

ICF Domain: Neuromusculoskeletal and movement-related functions

b760 – Control of voluntary movement functions
b7602 – Coordination of voluntary movements – functions associated with coordination of simple and complex voluntary movements, performing movements in an orderly combination.

Inclusions: right left coordination, coordination of visually directed movements, such as eye hand coordination and eye foot coordination; impairments such as dysdiadochokinesia

b765 – Involuntary movement functions
b7651 - Tremor

ICF Component: Activities and Participation

ICF Domain: Self-care
d550 – Eating – Carrying out the coordinated tasks and actions of eating food that has been served, bringing it to the mouth and consuming it in culturally acceptable ways, cutting or breaking food into pieces, opening bottles and cans, using eating implements, having meals, feasting or dining.

d560 – Drinking

ICF Component: Environmental Factors
ICF Domain: Support and relationships
e315 – Extended family

ICF Domain: Attitudes
e415 – Individual attitudes of extended family members

ICF Domain: Services, systems and policies
e580 – Health, services, systems and policies
e-5802 – Health policies

Potential Interventions

1. Teach the patient’s niece the primary symptoms of Alzheimer’s disease (amnesia, aphasia, apraxia, and agnosia), and how each of these symptoms can influence the patient’s functional ability and level of cooperativeness at mealtime.

2. Explore strategies to decrease the patient’s wandering at mealtime (toilet before meals; take the patient for a walk before meals to expend excess energy; wait to seat patient when the meal is actually ready and on the table; position the patient in a comfortable, supportive chair positioned directly in front of the table).

3. If wandering persists or if the use of utensils is challenging for the patient due to apraxia, consider adding finger foods such as sandwiches, slices of fruit, chicken strips, etc.

4. Limit the number of utensils and items on the table to decrease confusion and distractions.

5. Give the patient one item of food at a time, so that the presentation of the food is not overwhelming and then the patient is less likely to become frustrated and walk away from the table.

6. Limit verbal cueing to one step at a time. Physical cueing such as putting the cup in the patient’s hand, initially guiding the spoon to the patient’s mouth may also be helpful for initiation of the self-feeding activity.

7. Eliminate unnecessary environmental stimulation that may distract or upset the patient (turn off television, avoid eating with large numbers of other people, etc.).

8. Consider fortified supplements after a meal if intake is poor. Or consider multiple small meals or other finger foods throughout the day, to ensure adequate intake.

9. Initially to stimulate appetite, give the patient her favorite foods to eat.

10. Consider adaptive feeding equipment such as weighted utensils, no spill cups, bumper plates to increase the patient’s independence with eating.

11. Cut or prepare food in a manner and consistency that maximizes the patient’s ability to eat it.

12. Look for signs of poor dental hygiene, gingivitis and refer to dentist when appropriate. Pain when chewing may be affecting the patient’s oral intake. If the patient has oral heat and/or cold sensitivities, provide liquids and some food more at room temperature. If the patient routinely wore dentures, make sure the patient has them in her mouth and that they fit properly.

13. Assess the patient’s medication regimen to see if any of the medications could be contributing to the patient’s tremor, or poor appetite and notify the physician.

14. Check the patient’s bowel habits to make sure constipation is not causing loss of appetite.

15. Monitor the patient’s weight at regular intervals.

16. Try to have someone else eat at the same time the patient is eating so that behavior modeling can potentially occur.

17. Assess for psychiatric symptoms (depression, paranoid delusions) that could result in a decreased food and fluid intake and notify the physician.

Coding Information



ICD-10-CM Codes that Support Medical Necessity

Group 1

(3 Codes)
Group 1 Paragraph


Group 1 Codes
G30.0 Alzheimer's disease with early onset
G30.1 Alzheimer's disease with late onset
G30.8 Other Alzheimer's disease

Group 2

(7 Codes)
Group 2 Paragraph


Group 2 Codes
G30.9 Alzheimer's disease, unspecified
R25.0 Abnormal head movements
R25.1 Tremor, unspecified
R25.2 Cramp and spasm
R25.3 Fasciculation
R25.8 Other abnormal involuntary movements
R25.9 Unspecified abnormal involuntary movements

ICD-10-CM Codes that DO NOT Support Medical Necessity


ICD-10-PCS Codes


Additional ICD-10 Information


Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.


Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.


Revision History Information

Revision History DateRevision History NumberRevision History Explanation
10/01/2022 R6

Under Article Text – Description of scenario using ICD-10 removed F02.81. Under ICD-10-CM Codes that Support Medical Necessity Group 1: Codes deleted F02.81. This revision is due to the Annual ICD-10-CM Update and will become effective on 10/1/22.

05/12/2016 R5 Under Article Text – ICF Domain: Functions of the digestive metabolic and endocrine systems added a “s” to the description of b530. Under ICF Domain: Neuromusculoskeletal and movement related functions for b7602 deleted “coordination” as it was redundant. Under ICF Domain: Self-care for d550 added “the” to the first paragraph.
06/11/2015 R4 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed from the LCDs. For consistency, they are also being removed from the articles.
05/21/2015 R3 Under Article Guidance removed red lettering per 508 compliance, made a few grammatical and punctuation corrections, under #2 changed the word "plate" to "table" in the description and #16 added the word "eating" to the sentence.
Under Bill Type Codes removed 033x Bill Type per Change Request 8244.
10/01/2015 R2 Added ICD-10 codes from the Text to ICD-10 Codes Section. Added the phrase "used as a secondary diagnosis" to the appropriate codes in the Text section. Added Keywords.
10/01/2015 R1 Article validation

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Updated On Effective Dates Status
09/22/2022 10/01/2022 - N/A Currently in Effect You are here
05/05/2016 05/12/2016 - 09/30/2022 Superseded View
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  • Alzheimer's