UTI and Encephalopathy
Good morning everyone!
I am wondering how you r sequencing the above. Our coders always want to putnthe UTI first since it caused the
Encephalopathy. If the pt comes in with confusion why can't it go first if it is due to the uti and no other contributing issue are present?
Thanks so much!
Mary Hosler
Sent from Samsung tablet
I am wondering how you r sequencing the above. Our coders always want to putnthe UTI first since it caused the
Encephalopathy. If the pt comes in with confusion why can't it go first if it is due to the uti and no other contributing issue are present?
Thanks so much!
Mary Hosler
Sent from Samsung tablet
Comments
That being said, I am curious to know if our practice is consistent with other facilities.
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
A UTI is normally treated in an outpatient setting. If you can get the physician to document clearly that he is admitting the patient due to the encephalopathy and his concerns, I would feel comfortable using it as a principal diagnosis. If the encephalopathy truly is significant, you should see some diagnostics and increased nursing resources.
My thoughts anyway.
Great explanation Katy.
Marty Conroy
Director CDI
Temple Health
Thanks,
-Jane
p 303-603-9581
c 720-305-7765
Sequencing would depend published coding rules, the merits of the individual case, to include the diagnostic efforts, treatment, targeted time assessing the diseases with the accordant plan of care, and so forth. If time permits, permits consult with Case Mgmt and see which condition may have used per McKesson or InterQual evaluate the rationale for the admission –
I’d look for the stated etiology of the encephalopathy: alcoholic, hepatic, hypertensive, Toxic, Septic, and so forth
Depending on the cause, sometimes the encephalopathy is the PDX: (Rarely IMO)
VOLUME 19 FIRST QUARTER
NUMBER 1 2002, Page 3
Hepatic Encephalopathy versus Alcoholic Liver Cirrhosis
Question: What is the proper diagnosis sequencing for a patient who is admitted with hepatic encephalopathy and alcoholic cirrhosis? There is disagreement among our coding staff whether the underlying condition (the cirrhosis) or the acute manifestation (the hepatic encephalopathy) should be the principal diagnosis.
Answer: Assign code 572.2, Hepatic coma, for the hepatic encephalopathy, as the principal diagnosis. Assign code 571.2, Alcoholic cirrhosis of liver, as a secondary diagnosis. In the case of alcoholic cirrhosis with resulting hepatic encephalopathy, the hepatic encephalopathy is a life-threatening event that requires immediate treatment. Thus the hepatic encephalopathy should be sequenced first. The focus of treatment is generally aimed at the trigger of the encephalopathy, such as an infection or a heavy dose of alcohol consumption, not at the cirrhosis itself.
Coding advice on code assignments contained in this issue effective with discharges March 15, 2002
Encephalopathy:
Codes:
348.30 Encephalopathy, unspecified MCC
348.31 Metabolic encephalopathy MCC
348.39 Other encephalopathy MCC
349.82 Toxic encephalopathy MCC
572.2 Hepatic encephalopathy MCC
291.2 Alcohol induced persisting dementia CC
293.9 Unspecified transient mental disorder in conditions classified elsewhere CC
437.2 Hypertensive encephalopathy CC
These are the most common encephalopathy diagnosis codes that are classified as MCCs or CCs.
Definitions: Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by an infectious agent (bacteria, virus, or prion), metabolic or mitochondrial dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation, paints, industrial chemicals, and certain metals), chronic progressive trauma, poor nutrition, or lack of oxygen or blood flow to the brain. The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms include progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. The majority of encephalopathies are reversible.
· 349.82 Toxic encephalopathy – Brain dysfunction caused by infection, organ failure, or intoxication
· 348.31 Metabolic encephalopathy – Always has an underlying cause, such as brain tumors, brain metastasis, cerebral infarction or hemorrhage, cerebral ischemia, poisoning, systemic infection, etc. It is a common finding in patients with multiple organ failure. Metabolic encephalopathy may be the first manifestation of a critical systemic illness such as sepsis.
· 572.2 Hepatic encephalopathy – Arises from advanced cirrhosis of the liver or acute liver failure
· 291.2 Alcoholic induced persisting dementia – Alcoholic encephalopathy is indexed to this code and the condition arises from thiamine deficiency, usually in the setting of alcoholism and malnutrition.
· 437.2 Hypertensive encephalopathy – An acute or subacute consequence of severe hypertension marked by headache, obtundation, confusion, or stupor, with or without convulsions
· 293.9 Unspecified transient mental disorder in conditions classified elsewhere -- Transient dialysis encephalopathy is indexed to this code and the condition arises from increased aluminum found in the water used with renal dialysis.
SUPPORTING DOCUMENTATION:
History and Physical: Check the History and Physical for documentation of a change or altered mental status. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness. Other neurological symptoms may include myoclonus (involuntary twitching of a muscle or group of muscles), nystagmus (rapid, involuntary eye movement), tremor, muscle atrophy and weakness, dementia, seizures, and loss of ability to swallow or speak. These symptoms may be present in a patient with a history of cirrhosis, alcoholism, severe hypertension, poor nutrition or experiencing an acute infection.
Diagnostic Work-up: The diagnosis is usually clinically determined by bedside judgment of the physician, who may conduct neurological tests of mental status, blood tests, spinal fluid examination, imaging studies, and electroencephalograms.
Laboratory Results: Blood ammonia levels may be elevated or thiamine or zinc levels may be low. Cerebral spinal fluid may have mild protein elevation.
Associated Pathology:
AIDS, alcoholism or intoxication, cirrhosis of liver, exposure to toxins, hepatitis, hypertension, hypoxia, sepsis or infectious causes, organ failure.
Medications: Neomycin, lactulose, antibiotics, Flagyl, Rifaximin, Flumazenil, thiamine replacement, zinc, anti-convulsants and/or treatment of the underlying cause of the encephalopathy.
Surgical Therapies: Liver transplant
Non-surgical Therapies: Dialysis
Final Note/Summary: Review documentation for underlying cause or associated disease process of the encephalopathy.
REIMBURSEMENT ISSUES:
Many encephalopathy codes are MCCs. Encephalopathy may be a more specific diagnosis associated with documentation of delirium, altered mental status, acute confusional state, psychosis, and hallucinations. A review of the documentation of underlying disease processes with current symptoms present may indicate an additional or more specific diagnosis could be made. A query to the physician asking if a more specific diagnosis is appropriate to document the patient’s mental status, could gain an MCC or CC.
One example: Sepsis due to a UTI, MS-DRG 872 Septicemia or severe sepsis without mechanical ventilation 96+ hours without MCC. If an additional diagnosis of metabolic encephalopathy was documented it would change the DRG to 871 septicemia or severe sepsis without mechanical ventilation 96+ hours with MCC, which has a significantly higher reimbursement.
CODING AND COMPLIANCE ISSUES:
For a patient admitted with hepatic coma or encephalopathy with underlying cirrhosis of the liver, it is the acute manifestation of hepatic encephalopathy that is the principal diagnosis. Treatment is usually focused on the encephalopathy, not the cirrhosis. See Coding Clinic First Quarter 2002, page 3, Hepatic Encephalopathy versus Alcoholic Liver Cirrhosis, for an example.
If encephalopathy is present with viral hepatitis or chronic hepatitis use the combination code that includes hepatic coma. For example, if hepatic coma or hepatic encephalopathy (572.2) is documented along with chronic hepatitis C (070.54) use the combination code, chronic hepatitis C with hepatic coma; code 070.44. If hepatic encephalopathy is due to viral hepatitis with cirrhosis, only code the combination code for hepatitis with hepatic coma. See Coding Clinic Second Quarter 2007, page 6,Hepatic Encephalopathy Due to Viral Hepatitis.
Encephalopathy due to a postictal state after a seizure is not reported, as it is integral to the condition. See Coding Clinic Fourth Quarter 2013, page 89, for more information.
Posterior reversible encephalopathy syndrome (PRES) is a term being used by some neurologists to refer to reversible posterior leukoencephalopathy syndrome (RPLS). Assign code 348.39, Other encephalopathy, for this condition. See Coding Clinic Third Quarter 2006, page 22, Posterior Reversible Encephalopathy Syndrome (PRES) for more information about this condition.
Transient dialysis encephalopathy is usually due to increased aluminum found in the water used with renal dialysis. Excessive concentration of aluminum in the body due to dialysis is classified as a poisoning, reported with 985.8, Toxic effect of other metals, with E879.1, Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure. Assign additional codes for any manifestation, such as transient dialysis encephalopathy, 293.9, Unspecified transient mental disorder in conditions classified elsewhere, or dialysis encephalopathy (not specified as transient) 294.8, Other persistent mental disorders due to conditions classified elsewhere.
Dialysis encephalopathy without mention of aluminum intoxication or aluminum overload is reported with 293.9 for transient and 294.8 for dialysis encephalopathy not specified as transient, along with E879.1. See Coding Clinic First Quarter 1988, page 3, Metabolic Encephalopathy.
If encephalopathy is diagnosed in a newborn, for example (HIE) Hypoxic-ischemic encephalopathy, review Coding Clinic Fourth Quarter 2009, page 99, Hypoxic-Ischemic Encephalopathy, and Fourth Quarter 2006, page 104, Hypoxia, Hypoxia Ischemic Encephalopathy
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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From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 06, 2015 8:50 AM
To: Evans, Paul
Subject: RE: [cdi_talk] UTI and Encephalopathy
Katy is spot on. Her explanation below is exactly how I would expect my team to analyze a case.
Great explanation Katy.
Marty Conroy
Director CDI
Temple Health
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 06, 2015 9:20 AM
To: Conroy, Martin
Subject: RE: [cdi_talk] UTI and Encephalopathy
Our coders do the same. I think the argument against coding encephalopathy as Pdx is; where is the treatment directed? Because we know the underlying cause of the encephalopathy, I am assuming these patients do not receive a neuro consult, EEG, or other diagnostic studies. There is no treatment being directed at this dx besides supportive care (keeping the patient safe). We understand that the encephalopathy will resolve as we treat the infection. So the treatment is being directed at the uti, likely with IV antibiotics. Now, if (by chance) the patient was only receiving oral abx and it was clearly documented that the patient was admitted for their altered mental status, you may have something there because the argument could be made that the UTI could have been treated OP. That being said, you should be prepared to defend this because encephalopathy as Pdx is a RAC target and it will be scrutinized and likely denied. We generally sequence the underlying cause first and encephalopathy is coded as PDX in instances where no underlying cause is known and care is clearly directed at this issue (or the obvious case of hepatic enceph).
That being said, I am curious to know if our practice is consistent with other facilities.
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
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, February 06, 2015 6:02 AM
To: Kathryn Good
Subject: [cdi_talk] UTI and Encephalopathy
Good morning everyone!
I am wondering how you r sequencing the above. Our coders always want to putnthe UTI first since it caused the
Encephalopathy. If the pt comes in with confusion why can't it go first if it is due to the uti and no other contributing issue are present?
Thanks so much!
Mary Hosler
Sent from Samsung tablet
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