Postop Delirium versus Toxic Metabolic Encephalopathy

kkurokawakkurokawa
in Clinical & Coding

I have a case where the patient developed sudden “postoperative delirium” after an orthopedic surgery.  Prior to surgery the patient was alert and oriented.

The provider documents the postop delirium is due to being kept awake very late last night for surgery as well as the anesthesia she received.  The patient is treated with one dose of Haldol.  By the next day, the delirium is resolved.  Patient is alert and oriented again.  Brain CT, EKG  and other work up unremarkable.

 My question:  could this be toxic metabolic encephalopathy or is this postoperative delirium (as documented)?

Thank you in advance for guidance.

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    This is very complicated and justice can’t ‘be done’ via typing. But, re: toxic encephalopathy, you may wish to consider that the code in this scenario  for this condition represents a ‘toxicity’ reported as NOT present on admission, and caused by medical care.   Encephalopathy caused by medications would be coded as either an adverse effect of properly prescribed medications or, if the circumstances reveal any ‘error’ in route, dosing, or so forth, this would actually be reported as a ‘poisoning’.  Proceed with caution.

    As I said, too complicated for this forum.

    Paul Evans, RHIA, CCDS
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