Seizure and encephalopathy

I am looking for advice on the coding of seizures and encephalopathy. Our coders have indicated that if a patient is admitted for seizures and also has a diagnosis of encephalopathy, the encephalopathy should not be reported as an MCC due to the fact that encephalopathy is "inherent" in seizure.

I have not been able to find a Coding Clinic that supports this assumption, but perhaps I am missing something. Anyone out there have insight into this?



Robin Van Vught, RN
Clinical Documentation Specialist
Meriter Hospital



  • edited May 2016
    Afraid I have to disagree with your coders based on the info provided.

    The CC below supports coding encephalopathy along with epilepsy. I would presume the same advice applies to ‘seizures’ which, if recurrent, would be coded to epilepsy. Hope this helps -

    Admission for evaluation and initiation of ketogenic diet
    Coding Clinic, Third Quarter 1997 Page: 5 Effective with discharges: August 1, 1997
    Related Information


    A 5 year old child was admitted to the hospital for evaluation and initiation of a ketogenic diet. The patient has been diagnosed as having myoclonic encephalopathy and psychomotor developmental delay. He has responded fairly well to Depakote prior to admission, but he was still having intermittent myoclonic seizures. The record states he was admitted electively for initiation of ketogenic diet. What should the principal diagnosis code be?


    Note from 3M:
    As of October 1 2000, code 783.4 has been expanded to the fifth digit level for further specification.
    Note from 3M:
    As of October 1, 2003, code 348.3 has been expanded to the fifth digit level for further specification.
    Assign code 345.1, Generalized convulsive epilepsy, for the myoclonic seizures, as the principal diagnosis. However, if the physician states that the patient has familial or progressive myoclonic seizures, assign code 333.2, Myoclonus. In addition, assign code 348.3, Encephalopathy, unspecified, for the myoclonic encephalopathy; and code 783.4, Lack of expected normal physiological development for the psychomotor developmental delay.

    © Copyright 1984-2012, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    213-250-4200 Extension 3336
  • I have never heard that argument. I would argue strongly against it. Encephalopathy may be caused by the Sz. However, it is certainly not present with every patient suffering a Sz. The documentation of encephalopathy would indicate to me an increased severity of illness for this patient and should be coded IMO. Unless they have a Coding Clinic backing them up, I don’t get their argument.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Cell: 928.814.9404
  • edited May 2016
    I agree with Katy!!

    And disagree with your coding staff... Now days, if you wake up after the seizure (depending on the cause)... you are likely not even be admitted as an inpatient. You would go home for outpt workup.

    Enceph could have been caused by another condition and may have been metabolic or even toxic in nature. Whatever caused the enceph may have also caused seizure. I am not aware of a coding clinic that supports "not coding" the enceph. Enceph is always caused by something else. Seizures and Enceph can both be symptoms of the same underlying condition or both could be caused by two unrelated conditions. No way inherent! (And before even going down that route, I would want clarification from the MD that the seizure actually caused the enceph. Sounds more like an assumption.)

    This article may help... Brian Murphy's White paper regarding Enceph. The article can be viewed by clicking on the link below.

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens
  • Agree : we should code the encephalopathy as an additional condition. The reference provided from Coding Clinic makes this very clear.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
  • When I first read this, I was wondering how the physician documentation well as whether the coders were confusing a postictal state
    with encephalopathy.

    Yes, postictal state is inherent to a seizure. Encephalopathy is not
    and I believe one with a good clinical insight can reasonably
    differentiate between the two.

    Is there one physician (or several) that are using the term
    encephalopathy to describe the condition for many/most seizure patients
    when really just postictal?

    As CDS's, we need to carefully use our judgement on when there is
    something significantly 'different' about the patient's described
    condition, return to baseline, or additional resources, treatment or
    evaluation aimed at an altered mental status. Additionally, was there
    some clinical insult (perhaps hypoxia, metabolic or electrolyte
    abnormalities due to prolonged seizure state) that might lean more
    toward an encephalopathy vs normal seizure recovery.

  • edited May 2016
    Don and Katie, is there such a thing as postictal encephalopathy? We have had some Docs even call it postictal psychosis.

  • Jane,

    See an abstract on pub-med from 1990 that describes the condition

    Also on pub-med from 1992

    Another brief reference from 2005:

    There does not seem to be very much out there in the literature (based
    on a casual search) so I am not certain how widely this state either
    occurs or how broadly it is accepted. For that significantly prolonged
    period perhaps this is a useful diagnosis. From the brief readings, I'd
    say the time period is likely at least 24 hours if not 36 hours, but I
    have not read any of the original articles (just skimmed the

    One of the alternative causes that needs to be investigated is if there
    is continued seizure activity in the brain.

  • edited May 2016
    Thank you for your reply. I did look at those sources. Good information for me.

  • Hi all
    I realize this thread is a bit old but I am currently dealing with the issue of coding/not coding  postictal encephalopathy.  I feel that the 2013 Coding Clinic below is instructing NOT to add a code for the encephalopathy.  Any thoughts/comments would be appreciated.

    Seizure with encephalopathy due to postictal state, Coding Clinic, 4th Quarter 2013, p. 89-90

    Question:  The patient is a 70-year-old female who presented to the emergency department (ED) because of mental status change. While in the ED, she had a tonic-clonic seizure that was witnessed by staff. The patient had no previous history of seizure and was admitted as an inpatient for further evaluation and management. In the discharge summary, the provider noted, "On admission the patient had mental status changes, which subsequently resolved. Consequently, we have determined that the patient had encephalopathy secondary to postictal state." Should encephalopathy be reported as an additional diagnosis with seizure when it's due to a postictal state? Would the encephalopathy be considered inherent to the seizure or can it be separately reported?

    Answer:  Assign code 780.39, Other convulsions, as the principal diagnosis. The encephalopathy due to postictal state is not coded separately since it is integral to the condition. Seizure activity may be followed by a period of decreased function in regions controlled by the seizure focus and the surrounding brain. The postictal state is a transient deficit, occurring between the end of an epileptic seizure and the patient's return to baseline. This period of decreased functioning in the postictal period usually lasts less than 48 hours. 
  • Hi Maggie! 
    I was always taught not to code, and have had outside auditors agree, if within that “normal” postictal period. I always looked to validate the dx of encephalopathy if it extended time, additional resources started being extended beyond our facilities norm, etc.. 

    might be worth revisiting the topic with coding clinic. 

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