Hepatic encephalopathy

rvanvught

I am wondering if anyone cares to weigh in on the issue of hepatic encephalopathy.

When you see a patient with advanced liver disease being treated with lactulose/Rifaximin, do you query whether these drugs are treating hepatic encephalopathy even if the patient is not documented to be experiencing AMS/other observable signs of the encephalopathy during the current admission?

We have received advice from our consultants to query for this diagnosis in this situation, but we have had some hesitation.

Thanks!

Robin

robert.hodges2

Not me. You have to have clinical indicators before you can query. I see this fairly often and usually the treatment is to address the elevated ammonia levels. If there is a mental status change, then I do query for the underlying cause and if it is an acute vs. chronic change.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

katysuegood@gmail.com

I would not query without clinical indicators.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

rvanvught

Our consultants are basing this strategy on the following Coding Clinic, FYI:

Atrial Fibrillation on Medication Maintenance
Coding Clinic 3rd Qtr. 1995, p. 8

Question:
Is it appropriate to assign a code for chronic atrial fibrillation even though the patient isn't experiencing atrial fibrillation during this particular admission? The patient is maintained on Lanoxin and is admitted to the hospital with EKG and cardiac monitor documenting normal sinus rhythm.

Answer:
Yes, it would be appropriate to add atrial fibrillation (427.31) as an additional code assignment, when the physician has documented the condition in the medical record and has listed it in the final diagnostic statement. The patient now requires ongoing medication administration for control of this condition.

ssalinas

In the case below, the physician has documented the atrial fibrillation. In the example you gave, hepatic encephalopathy (or symptoms of) had not been introduced.

If a patient is receiving some kind of treatment and no diagnosis is listed to cover the treatment, a question could be asked if there is a dx to cover treatment. I believe someone has posted a form that worked for this situation. I believe it was called Treatment without diagnostic indication.

Sharon Salinas, CCS
Barlow Respiratory Hospital
213-250-4200 Extension 3336

sharon.cole

Still, if the patient isn't meeting criteria for encephalopathy, I wouldn't query for it. I would not have interpreted that coding clinic for hepatic encephalopathy. Afib is a chronic condition that requires continual treatment. Hepatic encephalopathy may occur as an acute, potentially reversible disorder. Or it may occur as a chronic, progressive disorder that is associated with chronic liver disease.


Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
Sharon.cole@phn-waco.org

evanspx@sutterhealth.org

A bit tricky - encephalopathy may be termed 'chronic' and it is controlled with medications, perhaps it would be valid to code it in the same logic cited in Coding Clinic for a-fib.

Paul Evans, RHIA, CCS, CCS-P, CCDS

mdominesey

People with chronic liver failure are often treated with lactulose on a daily regimen to prevent the buildup of Ammonia and the resulting enecphalopathy.

Personally, I woul at least ask the nurses taking care of the patient to see if the pt is confused, but without documentation of AMS, I wouldn't query.

Mark


Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695
W: 202.660.6782
http://www.sibley.org
mdominesey@sibley.org
________________________________________

catladyrn

IMO, the difference between the hepatic encephalopathy and the AF mentioned in the coding clinic is the wording, "when the physician has documented the condition in the medical record and has listed it in the final diagnostic statement." The AF has already been diagnosed and is being controlled by medication, which as others have said, puts it in the category of a chronic condition.

OTOH, your hepatic encephalopathy scenario, by not having even a hx of hepatic encephalopathy documented in the record, gives no evidence that the treatment is anything other than prophylactic due to the advanced liver disease. Maybe they just want to prevent encephalopathy.

Despite what some people may tell you, there are only a relatively few instances where you have hard-and-fast rules for querying a given diagnosis. Otherwise a bot could be programmed to generate queries.

Renee

Linda Renee Brown, RN, CCRN, CCDS, CDIP, CCS

sharon.cooper@owensborohealth.org

Yes, we code chronic encephalopathy if it is controlled by meds (ex. Home meds) - citing same coding clinic mentioned below relating to a-fib. The pt is not in a-fib because meds are controlling.

evanspx@sutterhealth.org

I am thinking of a different situation, and agree would not query for encephalopathy lacking signs and symptoms of same.

However, what about assigning code for 'hep c, chronic, with encephalopathy' AND the patient has H/O of same per H&P and maintained on lactulose to prevent acute decompensation?

(I think this is more in keeping with coding 427.31 (A-Fib) as a secondary condition because it is being treated with a drug).



Paul Evans, RHIA, CCS, CCS-P, CCDS

tpeyton

I wouldn't ask if they were no clinical indicators. I hope everyone is staying safe...thoughts and prayers for all those affected by the storm so far.

Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406

parrispa@musc.edu

We do not ask either unless we have clinical evidence to warrant a query.
My thoughts and prayers to all who have been affected by SANDY, as I live in Charleston, SC I can appreciate what you guys are going through


Pamela Parris,RN
Clinical Documentation Integrity
MUSC
Charleston, South Carolina 29425
Pager: 12295
(843) 792-3442
MAIN HOSPITAL

judithbates

I just went to a seminar about cirrhosis. AMS is actually one of the later stages of encephalopathy and today treatment is geared more towards prevention of these late effects. I would not hesitate to query for this or any other medication that didn't have a corresponding diagnosis.
My .02...
Judi Bates

katysuegood@gmail.com

I think one of the things to think about is how MD's will respond. We have had other suggestions similar to this made. One that comes to mind quickly is "malnutrition". There was a push that any patient receiving tube feeds should carry the diagnosis of malnutrition because we are PREVENTING malnutrition by feeding the patient. This objectively makes sense (do other facilities do this?) but our MD's were resistant. They did not feel that patients met criteria and the dieticians agreed.
Whether or not WE see how this treatment is resource intensive and we would like to capture this dx, I have found sometimes it's not worth pushing simply because of overall program buy-in. A program that has excellent MD support and understanding may be fine pushing this dx but I don't think mine are there.
I am hesitant to push MD's towards a dx that they are uncomfortable with. I am happy to educate on why it may be applicable, etc, but ultimately it is their choice. I do not want to compromise our relationship pushing a dx that they are unsure about. I know that at my facility there are plenty of documentation opportunities that the MD's are not resistant to. I want to focus on those dx first. I try to be careful about what queries I place because I have found that whenever an MD receives a query that they think is inappropriate (or they just don't understand it), I lose a little buy-in.

Just something to think about!


Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

catladyrn

Nicely said, Katy. I agree with you that every patient who receives a G-tube should not necessarily have a diagnosis of malnutrition. I once knew a CDS who queried for severe malnutrition every time she saw a low serum albumin. Yikes.

Maybe an analogy would be the patient who has CAD and receives Plavix to prevent an MI. They don't actually have an MI, and we would never query it and the coders wouldn't code it. We would only have the CAD. So the patient who has a diagnosis of cirrhosis and receives lactulose is likely prescribed the med to prevent encephalopathy, but without evidence of a prior diagnosis of encephalopathy or demonstrated evidence of a current condition, I'd be very leery of querying for encephalopathy.

Renee

Linda Renee Brown, RN, CCRN, CCDS, CDIP, CCS

judithbates

I agree, we do have to pick our battles...
JUDI

mulled2

From what I understand hepatic encephalopathy is not cod able in ICD 10 and it redirects you to hepatic failure with coma but I am finding our coders also wont take that.

arozhkovskaya

Here is how it codes in encoder, If this is documented due to chronic Hep C, it still codes to it.

[cid:image003.jpg@01D110BC.48BB5E30]

mulled2

Yes but it is not a cc or mcc anymore

From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, October 27, 2015 1:35 PM
To: Debra L. Mullen
Subject: RE: [cdi_talk] Hepatic Encephalopathy


Here is how it codes in encoder, If this is documented due to chronic Hep C, it still codes to it.

katysuegood@gmail.com

My understanding is that the MD's need to document the coma (if present) to capture an MCC for these cases. Hepatic encephalopathy routes to liver failure and there is no additional MCC. We have a high volume of patients with ESLD so this is something we evaluated as an area of financial risk as it was not uncommon that hepatic encephalopathy was the sole MCC on these cases and we will no longer have that. Many of these patients do not have hepatic coma, just confusion, lethargy, etc.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

LPeel

On a different note.......in ICD 9 & 10 whenever there is an excisional debridement we want to know the depth level. When there is only an Incision and Drainage of an abscessed av fistula, using a versajet, is the depth level required? I only see that the root operation information is appropriate in ICD 10
Thanks

Lori E Peel RN-BC, MSN
RN Quality Documentation Specialist
Phelps Memorial Hospital
Quality Assurance/Risk Management
914-366-3995
lpeel@pmhc.us


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-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, October 27, 2015 3:10 PM
To: Peel, Lori
Subject: RE: [cdi_talk] Hepatic Encephalopathy

My understanding is that the MD's need to document the coma (if present) to capture an MCC for these cases. Hepatic encephalopathy routes to liver failure and there is no additional MCC. We have a high volume of patients with ESLD so this is something we evaluated as an area of financial risk as it was not uncommon that hepatic encephalopathy was the sole MCC on these cases and we will no longer have that. Many of these patients do not have hepatic coma, just confusion, lethargy, etc.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator AHIMA Approved ICD-10CM/PCS Trainer Flagstaff Medical Center Kathryn.Good@nahealth.com
Cell: 928.814.9404


-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, October 27, 2015 11:33 AM
To: Kathryn Good
Subject: RE: [cdi_talk] Hepatic Encephalopathy

From what I understand hepatic encephalopathy is not cod able in ICD 10 and it redirects you to hepatic failure with coma but I am finding our coders also wont take that.

-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Tuesday, October 27, 2015 12:58 PM
To: Debra L. Mullen
Subject: [cdi_talk] Hepatic Encephalopathy

Hello All,

I am hoping that you all might be able to help me wrap my brain around this issue. With the ICD-10 implementation our coders are telling us that in order to code a hepatic encephalopathy the MD has to specifically state (acute of chronic) Hepatic failure with coma and that hepatic encephalopathy is not a code-able term with the transition. I looked this up in the coding clinics and the only clinics that I can find are from 2007. There so happens to be one that is my patient exactly "Coding Clinic, Second Quarter 2007 Page: 6 to 7 Effective with discharges: June 30, 2007
Question:
What codes are assigned when the patient has hepatic encephalopathy due to chronic viral hepatitis C with cirrhosis?

Answer:
Assign code 070.44, Chronic Hepatitis C with hepatic coma, for hepatic encephalopathy due to chronic viral hepatitis C. Assign also code 571.5, Cirrhosis of liver without mention of alcohol, for the cirrhosis."

I have hepatic encephalopathy due to chronic Hepatitis C throughout the chart. It seems to me to be unnecessary to query the MD for a coma.
I even tried to find if there was a difference in definition of Hepatic encephalopathy and Hepatic Coma in Up To Date- both terms took me to the encephalopathy.

Any insight would be helpful,

April McClafferty RN, CDS
Baylor All Saints Medical Center
Fort Worth, Tx

april.mcclafferty@baylorhealth.edu

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Unknown

Other software will take encephalopathy, hepatic to liver failure where you identify acute K72.0x or chronic K72.1x liver failure and then with or without encephalopathy for the 5th digit of 0 or 1. Though the words used in description of the code state "coma," it's "hepatic encephalopathy" that gets you there. Hepatic encephalopathy and coma are synonyms unless the altered mental status in a liver failure patient is due to something else. This is still an MCC if it's a secondary diagnosis, as when the patient is admitted for pneumonia or something else. A coder who demands the word "coma" is not acting proactively in representing what's wrong with the patient. This kind of hesitance in linking clinical with coding language is hurtful to medicine. You'll see that the answer will come out supporting this if it's ever asked. Come on guys - let's stay real. The doctor does NOT have to document "coma." That's playing games and it's paranoia. Hepatic encephalopathy due to chronic liver failure is K72.11. Now, don't overdo it, either. If the patient is only on meds to keep the ammonia under control, the patient does NOT have encephalopathy now. Try to use the guise that "the patient is still being treated so you code it as an active disease." Be honest. If the patient does not have significant mental status change due to significant elevation of ammonia now, the patient does not have hepatic encephalopathy now. The meds are just for controlling ammonia level. Got it? Bad advice about this kind of stuff is all over the place.

Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)

evanspx@sutterhealth.org

The Index will take one to the series discussed by Dr. Gold if one references either 'coma' or "encephalopathy". The index then will 'ask' a series of refining questions to determine the underlying cause of the coma. I don't personally know of any coder that would insist upon the wording of 'coma' to assign a code for encephalopathy. All of the coders I work with are very familiar with encephalopathy and coma, and would know the terms are used interchangeably, and particularly as a manifestation of various forms of liver disease. We treat a lot of chronic Hep C patients, and we see this diagnosis very frequently w/ that population and our septic patients.

If you ever doubt the logic of an encoding software package, use a paper copy of I-10 to verify logic and code selection choices.


While we are discussing the topic of coma, you want to review the guidelines for capture and coding of the individual components of the GCS as these codes can capture important secondary conditions.




Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

katysuegood@gmail.com

Hmmm. Sounds like I need to talk to our coders. They want 'coma' right now....

When this first came up a couple years ago, they referenced this (UpToDate):

The severity of overt hepatic encephalopathy is graded from I to IV based on the clinical manifestations (table 2 and figure 1) (see "Hepatic encephalopathy in adults: Clinical manifestations and diagnosis", section on 'Clinical manifestations'):

●Grade I: Changes in behavior, mild confusion, slurred speech, disordered sleep

●Grade II: Lethargy, moderate confusion

●Grade III: Marked confusion (stupor), incoherent speech, sleeping but arousable

●Grade IV: Coma, unresponsive to pain


I think because there is this differentiation in severity, the understanding was that only the most severe patients should get the MCC (with coma). I would be thrilled to be able to convince them otherwise!

The concern mainly stems from a RAC standpoint I believe. Unfortunately there is a lot of fear because even when we know something is true clinically, auditors will use this type of coding terminology to deny claims. It's difficult to know when it is/is not ok to code without the exact terminology. For example, we don’t code brain compression from documentation of midline shift...

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

arozhkovskaya

Completely agree with Katy. Need all (coders and CDI) to be on the same page.

evanspx@sutterhealth.org

Katy: Yet more evidence that correct coding, if supported by explicit documentation and applied as per the guidelines, may be denied improperly by 3rd parties. There are no grades of severity for the hepatic diseases referenced earlier that cause a 'CURRENT' encephalopathy. I follow the advice offered by Dr. Gold in regards to ensuring clinical criteria is charted that supports a current code for 'active' encephalopathy.

Let us know what happens?

The only grades I find for types of coma are the Glascow Coma Scales, found in the R40.XX series. I believe your coding mgr is being a bit Draconian on this issue?

Paul

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

jriley

Try this: Show your coders that the description for the I-9 code for hepatic encephalopathy INCLUDES the synonymous term "hepatic coma." In I-10 it isn't as easy to identify that they mean the same thing, however in effect no change has occurred between the coding systems.

After reading Dr. Gold's analysis I went right to my coders and shared his insights along with showing them the I-9 code and description compared to the I-10. They have struggled with several cases since 10/1 trying to capture that MCC. They are thrilled to have confirmation from an expert that hepatic encephalopathy can and should be coded separately when clinically appropriate.

Judy

Judy Riley, RHIT, CCS, CPC
Coding/CDI Manager
LRGHealthcare
Lakes x 3315

evanspx@sutterhealth.org

In my view, sometimes the coders are 'stuck in the middle' between CDI and a 3rd party, such as a RAC; it seems from some of the anecdotal information stated on this blog, the coding practice is becoming changed by outside influences that misapply (sometimes) the rules stated per HIPAA...in other words, coders perhaps act a bit paranoid for fear of denial of coding claims. In such instances, understand the coders can be accused of false billing, and suffer many consequences. Yet another reason everyone involved in this process needs to follow and apply the same set of rules.




Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

katysuegood@gmail.com

I am definitely going to bring it up. The initial conversation was years ago when we first noted this I-10 change. A lot has happened since then. Hopefully I can do some convincing ;-).

That being said, this is a complex issue. The 'typical' definition of coma is 'unarousable unresponsiveness'. Realize this may not be the clinical definition of hepatic coma, but I think this is what people are getting hung up on. If we have alertness on one side of the continuum and coma on the other, there are many states in-between (confusion, stupor, obtundation), all there may indicate encephalopathy. I think this classic definition is what get everyone confused because the book and encoder basically route you to liver failure and prompt for whether there is a 'coma' or not. Many of these patients with hepatic encephalopathy do not 'look' comatose.

UpToDate includes this in its discussion of hepatic encephalopathy:
Signs and symptoms — Cognitive findings in patients with hepatic encephalopathy vary from subtle deficits that are not apparent without specialized testing (minimal hepatic encephalopathy), to more overt findings, with impairments in attention, reaction time, and working memory (figure 2 and figure 3) [18]. Patients with severe hepatic encephalopathy may progress to hepatic coma.

Which also seems to suggest that there is a progression to hepatic coma rather than hepatic encephalopathy being synonymous with hepatic coma.

I am not trying to be difficult here. I just like to explore both sides prior to going to coding with a suggestion.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

evanspx@sutterhealth.org

I believe your institution is 'over-thinking' this one and making it overly complicated - no offense intended. I have been coding for 20+ years and have never had the argument from a any coder that a pt clearly described by an MD as encephalopathic must also meet any parameters for a coma in order to apply the code for encephalopathy. I'd venture to guess that many pts experiencing encephalopathy are not 'in a coma'. The Coding Guidelines are pretty clear about how to code 'encephalopathy".

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

fishdl@shands.ufl.edu

Here is an excerpt from an ACP Hospitalist article by Dr. Pinson addressing Hepatic encephalopathy:

"The ICD-9 classification has only one code to describe hepatic encephalopathy. Most patients with hepatic encephalopathy are treated on a continuous basis with oral lactulose to lower blood ammonia levels, preserve mental status, and prevent coma. Much confusion and disagreement have clouded the coding of hepatic encephalopathy in patients with normal mental status who are taking lactulose. ICD-10 resolves the controversy by creating two codes: one for those “without coma” and another for those with significant symptoms (described as “with coma” in ICD-10). ICD-10 leaves the determination of what symptoms of hepatic encephalopathy constitute “with coma” to the physician."

I agree with his statement - ICD-10 leaves the determination of what symptoms of hepatic encephalopathy constitute "with coma" to the physician.

I personally would not code "with coma" unless it is documented, or if Coding Clinic guidance is published instructing coders to assign "with coma" when encephalopathy is documented. If the clinical picture of the patient supports "with coma" and it's not documented - I'd query.

katysuegood@gmail.com

Sorry Paul,
I think my comment was confusing. I do not believe that patients with encephalopathy must meet criteria of 'coma'. I mean the opposite. Most encephalopathic patients are NOT comatose. Our coders have no issue with coding encephalopathy in patients where it is documented. Encephalopathy generally encompasses many degrees of altered mental status (confusion, obtundation, stupor, coma, etc). Coma is just one form of AMS we see in encephalopathic patients.
I think this is why this is difficult is that in other forms of encephalopathy and coma, we would not say the two terms are equivalent. This makes the determination specific to hepatic encephalopathy and hepatic coma. I am seeing arguments to support both claims.

No offense taken from you Paul. Ever.


Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

evanspx@sutterhealth.org

Katy..Got it -no worry. Actually, I was UNDERTHINKING this one!!

After reading all of these comments and reviewing the choices in I-10, I, too, would issue query for pts with liver disease also described as encephalopathic. As others clarified, we now can code these as 'with' or 'without' COMA.



Altered Level of Consciousness

Please clarify the nature / etiology of the patient's altered level of consciousness/encephalopathy

Provider Query Response:*
0 Somnolence
0 Stupor
0 Coma
0 Persistent Vegetative State
0 Transient Alteration of Awareness
0 Unable to determine
0 Other (please specify)*

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org