Multiple Choice Options on Queries that go to the same code???

Example: if querying for type of encephalopathy, is it appropriate and compliant to list metabolic encephalopathy and septic encephalopathy as seperate response choices knowing that both choices go the same code (G9341). 

The same goes for other conditions that could go to the same code, like dementia with behavior disturbances/combative behavior/aggressive behavior. 

My concern with practices like this is that it may be leading the provider, because the net result is the same code. Is it better to list these options on the same line (i.e. metabolic/septic encephalopathy)?

If anyone has thoughts to help clarify this issue for me, any guidance would be greatly appreciated. 

Buddy Morgan, RN, BSN


  • I don’t think this is leading as long as the query is supported by clinical evidence with accordant clinical choices and as long as there are other choices such as other, unable to determine and so on.

    Many conditions with multiple descriptions are coded to the same code, such as the examples you provided.  Clinicians do not ‘know’ the indexing of diseases, and as long as the CDI offers them compliant choices congruent for each particular case, I feel the practice you describe is compliant. 

    Just to illustrate further, in your example, if the patient with documented Encephalopathy with clinical support was also described as having a hypertensive emergency and also had encephalopathy, unspecified, and  sepsis and severe hyponatremia, I would include the options of:

    1. Septic Encephalopathy
    2.. Metabolic Encephalopathy
    3.  Hypertensive Encephalopathy
    4.  Other type of Encephalopathy
    5.  Unable to further specific the type of Encephalopathy

    On pad..excuse typos

    Paul Evans, RHIA, CCDS

  • Thank you for the feedback Paul! Your response was very helpful!!!
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