encephaloapthy and drug-induced delirium

katysuegood@gmail.com

Hi all,
What do you do when both are documented (referring to the same changes in mental status)? It is my understanding that Encephalopathy encompasses delirium so what do you do if physicians are saying both. Obviously one is an MCC and one is a CC so it has impact. Neither documentation is really incorrect. I feel like our coders are more comfortable with coding the delirium because it sounds more specific to them and they are concerned about adding an MCC and getting denied because the insurer may state that delirium should have been coded instead.
Thoughts? Any guidance on this?

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

katysuegood@gmail.com

And please excuse my typos ;-)

Sorry!

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

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Copyright 2013

HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

kerryseekircher

Hi Katy-
I will query if the MD documentation is conflicting. For instance, if the specialist is saying encephalopathy but the attending is saying delirium, I will query. In the definition provided by uptodate; both acute confusion and delirium are considered components of encephalopathy but I'd rather air on the side of caution and ensure consistent documentation one way or another-especially since one is a cc and the other an mcc.
Whenever possible, to ensure proper coding, we have really tried to work with our MD's to carry this dx through the chart and into the d/c summary to avoid confusion and strengthen the chart.
In another scenario, if the MD is documenting 'metabolic encephalopathy; pt with persistent delirium from hyponatremia/infection'-I don't consider this example conflicting and would try to discuss this with the coder that the delirium is a component of the encephalopathy.
I also found this article by Dr. Pinson helpful in working with the MD's and Coding Dept:
http://www.acphospitalist.org/archives/2010/09/coding.htm

Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013

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Copyright 2013

HCPro, Inc., 75 Sylvan Street, Danvers MA 01923

katysuegood@gmail.com

I agree that consistent documentation would be preferable. This particular case is problematic because we initially have postoperative delirium documented (patent was placed in restraints, didn't recognize his wife, was combative, etc). The CDI queried for encephalopathy. The MD did respond with acute encephalopathy but said he was not sure yet of underlying cause and to ask the following hospitalist to respond. Later progress notes only say delirium and tie it to meds. D/C summery says delirium.
The coder did not code encephalopathy and says that this is the 'etiology' of the encephalopathy and therefore did not code encephalopathy.

I can understand not wanting to code the encephalopathy based off the query alone when the MD continues to say delirium, I guess we could have re-queried at discharge on that. But I do not agree that the delirium negates the encephalopathy or that the etiology of the encephalopathy is the delirium. I think it's the opposite. The nature of the encephalopathy is the delirium. Delirium would be like confusion, a symptom or the underlying brain issue (encephalopathy).

Great article by Dr. Pinson. 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

---
Copyright 2013

HCPro, Inc., 75 Sylvan Street, Danvers MA 01923