Denial Toxic Encephalopathy due to drugs

justamandakay

We are starting to see an increase in denial on  toxic encephalopathy due to drugs.  Insurance states that some level of AMS or decreased LOC is integral in cases like polypharmacy or effects of certain drugs.  We documentation linkage of toxic encephalopathy due to source.  We have GCS scores to help support.   Any thoughts or insight maybe missing?

rmhosler1

Did they give u an alternate code?

evanspx@sutterhealth.org

 Are patients presenting wth encephalopathy due to drugs self-administered improperly and or with use of illegal drugs, and/or is your facility coding encephalopathy as a consequence of medical administration of therapeutic drugs with a POA of “N”?

Sorry if seems a silly question, but it matters in context of topic.

efeclint@yahoo.com

justamandakay said:

We are starting to see an increase in denial on  toxic encephalopathy due to drugs.  Insurance states that some level of AMS or decreased LOC is integral in cases like polypharmacy or effects of certain drugs.  We documentation linkage of toxic encephalopathy due to source.  We have GCS scores to help support.   Any thoughts or insight maybe missing?

I received a denial recently regarding this. They replaced the G92 code with F19.10 (other psychoactive substance abuse , uncomplicated).

The AHA coding clinic is clear regarding sequencing of toxic encephalopathy if the substance is known.

As long as there is consistent documentation of toxic encephalopathy and the substance/s is/are known, G92 should be coded as a secondary diagnosis.

Any other thoughts on this?

kshumpert

I have had these denials as well.  Our auditors state that the condition is delirium.  I argue this as delirium isn't documented in the medical record, I use the DSM V definition for delirium to argue the reviewer's suggestion and I use UpToDate  Acute TME in Adults by Chalela and Kasner to support TME.  I have had success when I can point out other metabolic issues and when there is polypharmacy and we don't know what has been taken.  I rarely get one overturned for an opioid as they argue it is inherent to the drug.  I have found that I have better success when I can show more features than just confusion, multiple interventions and if the AMS lasted for much greater than the half-life of a properly administered medication.  Citing liver and renal diseases that may delay clearance is helpful as well.