Encephalopathy coded to G94

lhord@frhg.orglhord@frhg.org
in Clinical & Coding
The physician documented "Acute encephalopathy secondary to infectious etiology with urinary
tract infection". The coder coded G94- "

“Other disorders of brain in diseases classified elsewhere”

I asked her to query the MD for clarification but she wants to send it to the coding clinic.

Any input would be appreciated.

Thanks,

Lynn Hord RN,

Clinical Documentation Specialist

Rideout Hospital

lhord@frhg.org

 

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

     MD needs to state this is a more precise form of encephalopathy...such as 'metabolic".  Otherwise, G94 is correct code with wording you cited.  However,  should query for more specific type of encephalopathy IMO.  (This 'sounds' like metabolic to me).   (Does pt have sepsis)?

    Paul Evans, RHIA

  • lhord@frhg.orglhord@frhg.org
    Hi Paul,
    Thanks for your response.
    No, the patient didn't have sepsis.
  • ronna_mahlen@valleymed.orgronna_mahlen@valleymed.org

     MD needs to state this is a more precise form of encephalopathy...such as 'metabolic".  Otherwise, G94 is correct code with wording you cited.  However,  should query for more specific type of encephalopathy IMO.  (This 'sounds' like metabolic to me).   (Does pt have sepsis)?

    Paul Evans, RHIA

    Hi Paul,

    Can I ask what you would do if the MD documents both??  We see a lot of documentation that encephalopathy is multifactorial. i.e.

    Acute encephalopathy: poa, multifactorial,  due to effects of methadone/benzodiazepine and seizure. resolved" --I thought we could use the encephalopathy due to meds (toxic encephalopathy) as an MCC

    Thoughts??

    Ronna

    UW Valley Medical Center

    ronna_mahlen@valleymed.org


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

    Hi, Ronna

    There is a radio call tomorrow speaking about this very topic: I imagine it will be helpful.  As this condition may exist in multiple forms, represented by different 'codes', it would be appropriate to code as many types of encephalopathy that are present and clinically supported and clearly stated.  (Think of how many concurrent codes we can use for DM, as one example, or anemia).

    P. Evans, RHIA

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