RE: encephalopathy and drug-induced delirium
Consistency of the documentation is problematic, but I agree that 'delirium' is a FEATURE of encephalopathy, and that if a chart clearly states or links the 'delirium to the encephalopathy, only the encephalopathy is coded.
However, during longer and complicated stays, I have seen cases in which BOTH conditions were clearly documented as separate entities and coded separately.
Example: Admit with metabolic encephalopathy 2/2 Sepsis and this clears with treatment.
Subsequently, pt develops acute delirium 2/2 to a process not associated with Sepsis....such as 'acute drug-induced delirium'.
PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
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Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
However, during longer and complicated stays, I have seen cases in which BOTH conditions were clearly documented as separate entities and coded separately.
Example: Admit with metabolic encephalopathy 2/2 Sepsis and this clears with treatment.
Subsequently, pt develops acute delirium 2/2 to a process not associated with Sepsis....such as 'acute drug-induced delirium'.
PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
---
Copyright 2013
HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
Comments
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