I was wondering about Encephalopathy. As a CDS I go through the charts and pull together several different bits of clinical data. My coders are now queering the MD's every time they see "confusion" or "Altered Mental Status". Is this normal do other coders in other hospitals do this? I did not think they could.

Thanks Denise


  • Our coders do not query. Just because a chart says confusion or AMS does not mean encephalopathy. If they are asking for encephalopathy that sounds like a leading query to me.

    Amy Fenton, RN
    Clinical Documentation Specialist
    Clinical Operations Improvement
    Bronson Methodist Hospital
    601 John Street - Box 59
    Kalamazoo, MI 49007
    Office: (269) 341-8442
    Fax: (269) 341-8330
    Pager: (269) 513-3131
    E-Mail: fentona@bronsonhg.org
  • That's exactly what I thought but our consultant coder sent out an email to all the coders and told them to query if they saw those phrases. I can see the doing it for CHF and them needing further clarification, but the MD said CHF, in these cases the MD has not said encephalopathy. Our program allows the RN's to write seemingly leading questions kind of like if we were on the floor and we called the doc and said the pt is drowning I need some lasix.But I'm an RN I think the role is different between CDS's and coders.
  • edited May 2016
    What I do is if I see confusion or a mental status change is query for the underlying cause if it is not documented. It's part of my effort here to make the providers link symptoms to underlying conditions. It's a long battle, but it's making headway. Here is a copy of the query form I use for that. I'm attaching both Word 2007 and Word 97 formats.


    Robert S. Hodges, BSN, MSN, RN
    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

  • This is my first post! I hope I am doing this correctly. :)
    There is no coding clinic that states Encephalopathy should not be used as the principal diagnosis. Although encephalopathy is always due to an underlying cause, if it is after study, the condition that most likely caused this pts symptoms on admission - it can be sequenced as the principal diagnosis. In fact, Coding Clinic 1st Q 1988 p3-4 states: "Metabolic encephalopathy (delirium) may be designated as principal diagnosis if it is the condition established after study to be chiefly responsible for the admission of the patient to the hospital for care. Otherwise, it is listed as an associated condition that exists at time of admission or that develops subsequently"
    There are also no chapter specific guidelines for encephalopathy. The circumstances of the admission will always determine sequencing. The only exceptions would be if the encephalopathy is related to a poisioning - in which case, the poisoning code would be the primary diagnosis. In your case, in a pt with a UTI and pneumonia, cancer and acute renal failure, it could be the principal if this pts change in mental status is the focus of admission. For instance, if they were admitted with confusion or change in mental status and a CT and / or MRI was done, ammonia levels, lactate levels, EEGs, Neuro consult obtained, increase in resources like a bedside sitter, meds for agitation, etc... I could justify using the encephalopathy as principal. ( I do all of our RAC audits and always think in terms of an auditor) However, if this pts acute renal failure would require dialysis - obviously, this would be the more resource-intensive diagnosis and I would sequence it as the principal. If the pt came in with sepsis and had a septic encephalopathy, I would use the sepsis as principal. So basically - it depends on the focus of the clinical evaluation, the therapeutic treatments and diagnostic procedures and ultimately, the condition that most likely caused this pts symptoms on admission.
    Hope this helps!
    LeeAnn Conaway, RN, CCRN, CCDS
    UPMC Altoona, PA
    Clinical Documentation Coordinator
  • edited May 2016
    Welcome LeeAnn and thanks for the info :)

    Vanessa Falkoff RN
    Clinical Documentation Coordinator
    University Medical Center of Southern Nevada
    1800 W Charleston Blvd
    Las Vegas, NV
    office 702-383-7322

    Compassion * Accountability * Respect * Integrity
  • I agree. I find that when the underlying cause of the encephalopathy is known it is rare that it is the focus of care. For example if the patient is encephalopathic due to infection or renal failure, generally the underlying cause is the focus with the understanding that the encephalopathy will resolve with treatment of the underlying condition. So we may have a sitter, but we are not consulting neuro, doing EEG's or CT scans.
    Also, I have found that sequencing the underlying condition with encephalopathy as the MCC often garners the higher reimbursement.

    I think we can rest assured that when encephalopathy is sequenced as the Pdx, this account will be scrutinized by the insurer/RAC so make sure that this truly is defensible before assigning the encephalopathy as Pdx.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Cell: 928.814.9404
  • yes
  • Is encephalopathy INHERENT to a CVA? -- I don't believe so, therefore may possibly use as ODX.
    Was there significant monitoring, care, resource expenditure or LOS impact?
    Was there improvement in pt's mental status? (encephalopathy is reversible)

    With caveats, yes...


    Donald A. Butler, RN, BSN
    Manager, Clinical Documentation Advisor Program
    Vidant Health, Greenville NC
    DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )
  • edited May 2016
    The most common type of encephalopathy associated with CVA is hypoxic or ischemic. Patients may also have encephalopathy due to metabolic causes such as cerebral edema or brain compression.

    Wendy Clesi, RN, CCDS
    Director CDI Services
    Huff DRG Review
  • edited May 2016
    There is a coding clinic that mentions CVA as an underlying cause of met encephalopathy. See 4th q 2003 pg 58-59.

    Kerry Seekircher, RN, BS, CCDS, CDIP
    Clinical Documentation Specialist Supervisor
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013
  • Thank you all for responding.
  • I understand ACDIS Radio Talk will host Dr. Pinson in 2 weeks to discuss this topic.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.412.9421


  • Thanks Dr. G.

    Another scenario providers have been asking about is when there is postop acute confusion due to sedation. Would that be encephalopathy? I used to see them interchangeably use acute confusion and encephalopathy with postop patients. Personally, I would say no and look at what interventions you are doing for that patient. Are those interventions more for encephalopathy vs acute confusion? If maybe the acute confusion is sustained after a time period coming off of sedation, yes perhaps but not initially right after surgery. Besides, be careful to use encephalopathy postop as it is a ding to the surgeon in some cases like cardiac cases.

  • edited May 2016
    Thank you Dr G!

    Julie Monty
    RN, CCDS
    HIM Dept.
    (518) 314-3476
    The University of Vermont Health Network
    Champlain Valley Physicians Hospital

  • Hypercarbic Encephalopathy.....Would that be toxic metabolic, metabolic?

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