Traumatic Encephalopathy / Encephalopathy due to seizures.
Hello all 
I am curious as to what everyone else is doing regarding documentation of "traumatic encephalopathy." If physicians are documenting encephalopathy due to traumatic SDH, it is in turn being coded as "post concussion syndrome" and does not demonstrate the highest level of severity of illness of this patient. Trauma surgeons find it confusing (and frustrating) that if it truly is a traumatic encephalopathy, why does it code to a "concussion" when it is not a concussion?! How is CDI educating physicians surrounding this documentation in effort to capture this diagnosis appropriately?
Lastly, a new coding clinic from Fourth Quarter Oct. 2013, now states that encephalopathy is considered integral to the disease in the postictal state of a seizure. If not all patients experience a postictal state with seizures, does this coding clinic still apply? Do we no longer capture encephalopathy with any seizure? How would you query to clarify?
I look forward to your thoughts!
Cheers,
Lara Faustino RN, BSN, CCDS
I am curious as to what everyone else is doing regarding documentation of "traumatic encephalopathy." If physicians are documenting encephalopathy due to traumatic SDH, it is in turn being coded as "post concussion syndrome" and does not demonstrate the highest level of severity of illness of this patient. Trauma surgeons find it confusing (and frustrating) that if it truly is a traumatic encephalopathy, why does it code to a "concussion" when it is not a concussion?! How is CDI educating physicians surrounding this documentation in effort to capture this diagnosis appropriately?
Lastly, a new coding clinic from Fourth Quarter Oct. 2013, now states that encephalopathy is considered integral to the disease in the postictal state of a seizure. If not all patients experience a postictal state with seizures, does this coding clinic still apply? Do we no longer capture encephalopathy with any seizure? How would you query to clarify?
I look forward to your thoughts!
Cheers,
Lara Faustino RN, BSN, CCDS