Re: cdi_talk digest: July 21, 2010
I usually do query for encephalopathy on most "altered mental status" patients. But I review the chart for a possible clinical cause before I do. Our Enceph query allows us to check several conditions to supprt our query - for example, Sepsis/SIRS, Infection (usually its a UTI), uremia, dehydration, liver/hepatic disease, there's also a blank to enter abnormal LAB findings and a blank for medications (Toxic Encph includes Drug - which is a good place to indicate a patient who is not taking their meds correctly like the elderly.)
The important thing is to remember that encephalopathy is a manifestation of another condition.
Occasionally I run into a situation that does not fall into a "box" and I may verbal query the doc as to what he thinks may have caused the confusion.
CDI Talk digest wrote:
>CDI_TALK Digest for Wednesday, July 21, 2010.
>
>1. Encephalopathy
>2. Re: Encephalopathy
>3. re: chest pain
>4. Re: Encephalopathy
>5. RE: Unsupported diagnosis
>
>----------------------------------------------------------------------
>
>Subject: Encephalopathy
>From: davisd2@ah.org
>Date: Wed, 21 Jul 2010 16:49:39 -0400
>X-Message-Number: 1
>
>I was wondering about Encephalopathy. As a CDS I go through the charts and pull together several different bits of clinical data. My coders are now queering the MD's every time they see "confusion" or "Altered Mental Status". Is this normal do other coders in other hospitals do this? I did not think they could.
>
>Thanks Denise
The important thing is to remember that encephalopathy is a manifestation of another condition.
Occasionally I run into a situation that does not fall into a "box" and I may verbal query the doc as to what he thinks may have caused the confusion.
CDI Talk digest wrote:
>CDI_TALK Digest for Wednesday, July 21, 2010.
>
>1. Encephalopathy
>2. Re: Encephalopathy
>3. re: chest pain
>4. Re: Encephalopathy
>5. RE: Unsupported diagnosis
>
>----------------------------------------------------------------------
>
>Subject: Encephalopathy
>From: davisd2@ah.org
>Date: Wed, 21 Jul 2010 16:49:39 -0400
>X-Message-Number: 1
>
>I was wondering about Encephalopathy. As a CDS I go through the charts and pull together several different bits of clinical data. My coders are now queering the MD's every time they see "confusion" or "Altered Mental Status". Is this normal do other coders in other hospitals do this? I did not think they could.
>
>Thanks Denise
Comments
Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906
definitive criteria you can find, and then ask one of your neurologists
and one of your internists to speak with you about how they determine
the presence of encephalopathy. The perspectives may be different and
you'll want to know how neurology cases and critical care cases might
differ, as well as general medical/surgical cases. A case study of a
patient with metabolic, neurologic or other derangement who was
documented to have "confusion" or "altered mental status" could be
developed, showing the difference in codes and any impact on severity or
risk profiles. Make the point that the higher severity supports higher E
& M coding for them (evaluation and management-how they get paid) as
well as appropriate profiling for the hospital. This provides an
incentive for all parties.
Sandy Beatty, RN, BSN, C-CDI
Columbus Regional Hospital
2400 E. 17th Str.
Columbus, IN 47201
(O) 812-376-5652 (M) 812-552-6997
"Great leaders are almost always great simplifiers, who can cut through
argument, debate, and doubt to offer a solution everybody can
understand."
General Colin Powell