Septic encephalopathy

Good morning!

Does anyone have a reference that specifically states that documentation of "septic encephalopathy" can or cannot be coded as sepsis (038.9) with metabolic encephalopathy (348.31)???

The CDI pocket guide references "Septic encephalopathy is a clinical term that expresses brain disfunction as a manisfestation of severe sepsis, and is coded 348.31 (metabolic)."

This does not clarify if both sepsis and encephalopathy can be coded from this documentation as it does with septic shock and the need to use both codes 785.52 and 995.92.

We've had some differing thoughts amongst our physicians, our coders and CDI about how this can and should be interpreted but no one has offered a formal reference for their opinion.

Thanks for any help!

Jillian Lightfoot RN
Clinical Documentation Team
Marshall Medical Center
Placerville, CA 95667
(530) 626-2770 Ext. 6203
jlightfoot@marshallmedical.org
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