Encephalopathy?
Good Morning Fellow CDI Specialist and Happy Friday!
Our CDI Program is working on developing Query Guidelines for when to query for the diagnosis of Encephalopathy.
We have spoken to several physician's regarding when they think Encephalopathy is an appropriate diagnoses and have received several differences in opinions, which has left us quite confused!
So we would like to know in what circumstances you feel that it is appropriate to Query for Encephalopathy. A few of the circumstances that we are currently struggling with are AMS after a seizure or stroke. Some of our physicians feel that this AMS is an Encephalopathy, and some feel that it is an expected part of the diagnosis and not an Encephalopathy. Another example is if a patient has Encephalitis and the physician writes the patient is Encephalopathic could this patient be considered to have Encephalopathy?
Your thoughts on this topic would be greatly appreciated.
Thank you!
Greta
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
**********************************************************************************************************
This e-mail and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to whom they are addressed. This communication may contain personal patient health care information and is protected by federal law and other statutory protections. If you are not the intended recipient or the individual responsible for delivering the e-mail to the intended recipient, please be advised that you have received this e-mail in error and that any use, dissemination, forwarding, printing, or copying of this e-mail or any attached files is strictly prohibited. If you have received this e-mail in error, please promptly delete this message and notify the sender of the delivery error by e-mail or you may call Virginia Hospital Center -Arlington's Information Systems Department @703-558-6566.
***********************************************************************************************************
Our CDI Program is working on developing Query Guidelines for when to query for the diagnosis of Encephalopathy.
We have spoken to several physician's regarding when they think Encephalopathy is an appropriate diagnoses and have received several differences in opinions, which has left us quite confused!
So we would like to know in what circumstances you feel that it is appropriate to Query for Encephalopathy. A few of the circumstances that we are currently struggling with are AMS after a seizure or stroke. Some of our physicians feel that this AMS is an Encephalopathy, and some feel that it is an expected part of the diagnosis and not an Encephalopathy. Another example is if a patient has Encephalitis and the physician writes the patient is Encephalopathic could this patient be considered to have Encephalopathy?
Your thoughts on this topic would be greatly appreciated.
Thank you!
Greta
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com
**********************************************************************************************************
This e-mail and any files transmitted with it are confidential and are intended solely for the use of the individual or entity to whom they are addressed. This communication may contain personal patient health care information and is protected by federal law and other statutory protections. If you are not the intended recipient or the individual responsible for delivering the e-mail to the intended recipient, please be advised that you have received this e-mail in error and that any use, dissemination, forwarding, printing, or copying of this e-mail or any attached files is strictly prohibited. If you have received this e-mail in error, please promptly delete this message and notify the sender of the delivery error by e-mail or you may call Virginia Hospital Center -Arlington's Information Systems Department @703-558-6566.
***********************************************************************************************************
Comments
nature, Chronicity, and Underlying Cause of the change. Among the
choices (including other and unknown) is encephalopathy which also
request for type and cause if it is selected.
I guess my point is if symptoms are presented it's always best to query
for the underlying cause, and then further clarify if needed if you get
a vague response.
I hope this makes sense.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley
the other from NIH, NINDS: http://www.ninds.nih.gov/disorders/encephalopathy/encephalopathy.htm?
One is from the Revenue Cycle institute Q&A: http://blogs.hcpro.com/revenuecycleinstitute/2009/03/documentation-and-coding-for-toxic-metabolic-encephalopathy/
This is a useful article: http://www.healthline.com/galecontent/encephalopathy
Also from the American Stroke Association: Stroke and Encephalopathy After Cardiac Surgery: An Update
http://stroke.ahajournals.org/content/37/2/562.full
And of course, the Merck Manual on line is always an excellent resource (type encephalopathy into the search box, you may get more than you bargain for): http://www.merckmanuals.com/
Or go to the index for 'en': http://www.merckmanuals.com/professional/index/ind_en.html
Don