I have a chart where the px has been diagnosed with Lewy Body Dementia. I coded it with the G31.83 code followed by the F02.80 code. The documentation does not state whether or not the condition exist with or without behavioral disturbance and I cannot query the provider. So my auditor asked that I remove the F02.80 code. I thought this code is mandatory if it is in brackets. She says it only applies "if applicable" And since I don’t knowif the px has a behavioral disturbance or not, I have to remove the F02.80 code.

Can someone weigh in on this and let me know if my interpretation is correct? Or if my auditors interpretation is correct.