Geriatric medicine involves the diagnosis and management of complex, multi-system conditions in older adults including dementia, falls, polypharmacy, osteoporosis, and frailty. This page covers the top ICD-10-CM and CPT codes used by geriatricians and geriatric care specialists across the US.
Document all active chronic conditions at every visit — geriatric patients with 5+ conditions are the highest-value HCC capture opportunity in value-based care contracts.
Dementia codes (F01.x, F02.x, F03.x) must specify whether behavioral disturbance is present or absent — ‘without behavioral disturbance’ (F03.90) vs. ‘with behavioral disturbance’ (F03.91) significantly affects severity documentation.
Annual Wellness Visit (AWV) CPT G0438/G0439 is distinct from a preventive E&M and requires a Health Risk Assessment — both can be billed in the same year when scheduled at the correct interval.
Fall risk assessment and medication reconciliation for polypharmacy should be documented at each encounter as they are HEDIS measures affecting quality bonuses.
G30.9 is Alzheimer’s disease, unspecified. For coding dementia due to Alzheimer’s, use F02.80 (Dementia in other diseases classified elsewhere, without behavioral disturbance) or F02.81 (with behavioral disturbance) as the primary manifestation code, with G30.9 as the etiology code — per ICD-10 convention, code the manifestation first.
What is the Annual Wellness Visit CPT code?
G0438 is the Initial Annual Wellness Visit (AWV) under Medicare. G0439 is for subsequent years. The AWV is NOT a physical exam — it requires a Health Risk Assessment, an updated medical and family history, and a 5–10 year preventive care screening schedule. It can be billed alongside an E&M with modifier -25 if a separate problem is addressed.
What is R54 used for?
R54 (Age-related physical debility) captures frailty in older adults — a clinically significant syndrome affecting functional independence, hospitalization risk, and care planning. It is particularly important for risk stratification under value-based care models.
How do I code osteoporosis with a fracture?
If the osteoporotic fracture is current, use M80.0x1A (age-related osteoporosis with current pathological fracture, right side, initial encounter) or the appropriate site/side combination. M81.0 (without current fracture) is used when osteoporosis is present but no fracture has occurred.
How does OmniMD support geriatric care?
OmniMD’s Geriatric Medicine EHR includes cognitive assessment tools (MMSE, MoCA), polypharmacy reconciliation alerts, fall risk documentation templates (Morse Fall Scale), and value-based care dashboards for HEDIS measures.
Streamline Your Geriatric Medicine Practice with OmniMD
Purpose-built EHR, billing, and practice management for Geriatric Medicine practices.
