encephalopathy query

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
We have a patient that was admitted with altered mental status who was found to be uremic, in metabolic acidosis, with multiple electrolyte imbalances. In your opinion, is it leading to formulate a query with only the options of:
Hepatic encephalopathy
Metabolic encephalopathy
Toxic encephalopathy
Other
Unable to determine.

I don't like these options personally and am trying to provide feedback to the CDI who wrote it. I'm curious about other opinions.

Thanks!

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

Comments

  • annnd2009@gmail.comannnd2009@gmail.com
    edited April 2016
    I'd add
    No encephalopathy this admission (or present)

    Sent from my iPhone

  • jolene.filejolene.file
    edited April 2016
    Hi Katy!
    In my opinion, it is rather leading as you are only giving the opinions of encephalopathy.   Could delirium, intellectual disability or confusion be options? 
    TGIF!
    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Right. I feel like there should be some options that are not an MCC (other than unable to determine/other). That being said, I know if is ok to only have one option (other than unable to determine/other) if this is the only clinically reasonable choice. But toxic encephalopathy also was not a reasonable choice here (and we probably should have included uremic encephalopathy) as well.

    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

  • don.cdi.rn@gmail.comdon.cdi.rn@gmail.com
    edited April 2016
    You've not included indicators to support hepatic, so unless present
    would not have included that.
    Would include Acute Confusion as an option.
    If mental status sufficiently suppressed, could also consider coma.

    What was the underlying cause? was that sufficiently documented? with
    uremic, would be looking for evidence of ATN.

    Don

  • Unknown
    edited April 2016
    Katy,

    I would not take that as leading as you have given the physician an "out" by putting Other and unable to determine. with other- we place Other (please specify) __________________.



    Jamie Dugan RN CCDS

    Baptist Health System

    Jacksonville, Florida

  • hryfinskihryfinski
    Although they do give an out with "other" and "unable to determine," I would not be comfortable with this query. I would like to see some options included to further clarify the altered mental status OTHER than encephalopathy.

    I could see the use of these options if the encephalopathy was already documented and they query was to clarify the type.

    Hailey Ryfinski RN BSN
    Clinical Documentation Specialist
    ThedaClark Hospital
Sign In or Register to comment.