AMS and ALOC
Hello everyone,
This is my first time inquiring to CDI talk. I am having a difficult
time with physician documenting altered mental status (AMS) due to
infection and calling it Sepis when I further query for "Metabolic
Encephalopathy / Toxic Encephalopathy or Septic Encephalopathy."
Physican argued with me and said we don't ever use term
encephalopathy, we (physicians) call it altered mental status or
altered level of consicousness. We don't know the source the bacteria
etc.. All I was trying to clarify was it an encephalopathy of any
kind? To replace AMS / ALOC.
The doc told me AMS is codable, why would I call it encephalopathy?
It was clear in the documentation that pt was AMS in ER when admitted
last night by a different DR. This morning the doc tells me "but the
pt. is not AMS anymore" However she is septic, "we don't know the
source". I tried to explain to him that it does not mattter, she was
AMS upon admission and got reversible with IV fluids and 2 IV
antibitoics.
Pt lives at a SNF with indewelling foley cath and has UTI this
admission , has coccyx ulcers. I also query about medical device
related infection POA. MD said he's not sure UTI C&S is pending. I
understand there's a room for several physician quries but I was
tryiying to focus on encephalopathy.
I need suggestion and feedback on if I am pushing it too far or how to
handle this situation. Does anyone query for AMS / ALOC in this
situation?
Tanuja Bhattessa RN, BSN, CDS
@ Dameron Hospital Association
Stockton, CA
209- 944-5400 ext 3733
This is my first time inquiring to CDI talk. I am having a difficult
time with physician documenting altered mental status (AMS) due to
infection and calling it Sepis when I further query for "Metabolic
Encephalopathy / Toxic Encephalopathy or Septic Encephalopathy."
Physican argued with me and said we don't ever use term
encephalopathy, we (physicians) call it altered mental status or
altered level of consicousness. We don't know the source the bacteria
etc.. All I was trying to clarify was it an encephalopathy of any
kind? To replace AMS / ALOC.
The doc told me AMS is codable, why would I call it encephalopathy?
It was clear in the documentation that pt was AMS in ER when admitted
last night by a different DR. This morning the doc tells me "but the
pt. is not AMS anymore" However she is septic, "we don't know the
source". I tried to explain to him that it does not mattter, she was
AMS upon admission and got reversible with IV fluids and 2 IV
antibitoics.
Pt lives at a SNF with indewelling foley cath and has UTI this
admission , has coccyx ulcers. I also query about medical device
related infection POA. MD said he's not sure UTI C&S is pending. I
understand there's a room for several physician quries but I was
tryiying to focus on encephalopathy.
I need suggestion and feedback on if I am pushing it too far or how to
handle this situation. Does anyone query for AMS / ALOC in this
situation?
Tanuja Bhattessa RN, BSN, CDS
@ Dameron Hospital Association
Stockton, CA
209- 944-5400 ext 3733
Comments
that you meet criteria for severe sepsis. Here is a coding clinic that
may help you as well regarding Encephalopathy. You may want to remind
your provider that the AMA provides this guidance if you share it with
them.
Metabolic Encephalopathy
Metabolic encephalopathy refers to an altered state of consciousness,
usually denoting delirium. The delirium is either hypoactive or
hyperactive in form, is transient in nature, and is essentially a
reversible dysfunction in cerebral metabolism. The term "acute
confusional state" may be used by some physicians to describe metabolic
encephalopathy. The code assignments in the Alphabetic Index of ICD-9-CM
for delirium and acute confusional state are compatible. In most
instances, the associated condition or cause will be identified in the
physician's statement of diagnoses or in the body of the medical record.
A variety of conditions may cause metabolic encephalopathy (delirium),
such as brain tumors, malignant metastasis to brain, cerebral infarction
or hemorrhage, subdural or epidural hematoma, hypoxia, cerebral
ischemia, uremia, nutritional deficiency, poisoning, cumulative effect
of a prescribed drug, effect of drugs in various combinations, systemic
infection, meningitis, postoperative or post-traumatic states, postictal
state, hypoglycemia, severe burns, and drug or alcohol withdrawal.
Metabolic encephalopathy (see Delirium) refers to any of the following
conditions:
Acute delirium, 293.0 Acute alcohol withdrawal with delirium tremens,
291.0 Alcoholic delirium, 291.0 Drug-induced delirium (prescribed drug)
(non-prescribed drug) (cumulative effect of drug) (various combinations
of drugs), 292.81 Acute brain syndrome with transient delirium, 293.0
Acute delirium associated with systemic infection, 293.0 Uremic
delirium, 586
Not listed under Delirium, but of importance for coding purposes are the
following:
Sedative, hypnotic, or anxiolytic withdrawal delirium (developing after
cessation of or marked reduction in heavy use of a sedative, hypnotic,
or anxiolytic drug), 292.0 Alzheimer's disease with delirium, 290.11
Postictal state with delirium (confusional state in twilight epilepsy),
293.0
Coders are advised to read the inclusion and exclusion notes in the
Tabular List under 293, Transient organic psychotic conditions. In
keeping with the context of conditions excluded from category 293, the
following conditions are also excluded: drug-induced delirium (292.81),
delirium in alcoholism (291.0-291.9), and delirium due to
arteriosclerosis (290.40-290.43), senility (290.0), or senile dementia
(290.3).
Follow the instructional note under category 293 to use additional codes
to identify the associated physical or neurological condition.
Metabolic encephalopathy (delirium) may be designated as principal
diagnosis if it is the condition established after study to be chiefly
responsible for the admission of the patient to the hospital for care.
Otherwise, it is listed as an associated condition that exists at time
of admission or that develops subsequently.
AHA Coding Clinic(r) for ICD-9-CM, 1Q 1988, Volume 5, Number 1, Pages
3-4
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
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
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Yes, there is a 'code' for this, but the condition coded by this statement is 780.97 (Change in Mental Status).
I would explain to the MD the term AMS does little to explain the manifestation of the Sepsis - the term AMD does not equate to Encephalopathy. Therefore, we do query in this situation.
That condition (AMS) will not affect the Risk of Mortality or Severity of Illness, whereas the more precise term metabolic encephalopathy will affect the ROM/SOI, thereby accurately generating data truly reflecting the complexity of care and medical-decision-making of the MD.
You are correct to state that the apparent encephalopathy should be coded as it was POA and was reversed - the fact it is no longer present does not mean it should not be reported as it was managed, recognized and treated.
Here is one definition of Encephalopathy:
. Encephalopathy - a term for any diffuse disease of the brain that alters brain function or structure. May be caused by infectious agent (bacteria, virus, or prion), metabolic or mitochondrial dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation, paints, industrial chemicals, and certain metals), chronic progressive trauma, poor nutrition, or lack of oxygen or blood flow to the brain. The hallmark of encephalopathy is an altered mental state. (NIH Definition)
Paul Evans, RHIA, CCS, CCS-P, CCDS
Happy Friday to all
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054
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
to CDI talk. Thanks I feel supported. Happy Friday to all!!
Tanuja. Bhattessa. RN, BSN, CDS
Clinical Documentation Program Coordinator
Dameron Hospital Association
Stockton, Ca.
Central issue for CDI is that clinicians do not understand the exacting and quite literal language that is 'required' for accurate data - no one can code from clinical indicators.
Yet, time and time again, we are asked 'why can't you code shock if the BP is 90/50 and pt is on pressors?"
Ergo, posters with definitions can be useful tool.
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
evanspx@sutterhealth.org
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
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
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