Encephalopathy with Meningitis

chwcdichwcdi
in Pediatrics
We have recently seen denials coming through for coding encephalopathy with meningitis. The insurance companies are saying the encephalopathy should not be coded with the meningitis because altered mental status is inherent of the meningitis. We have attempted to fight this, but have not received an answer back yet. What is everyone's thought on coding the two together? Do other facilities code them together, or do you consider that every meningitis patient has encephalopathy?

Comments

  • dbeiseldentondbeiseldenton

    I would like to piggyback behind this question with another related question.  We see many patients that come to our ED intoxicated or overdosed on some drug.  In the ED, they describe the patients as sleepy but awake and talking, answering questions, he opens his eyes when his name is called.  Neurology exam states patient is alert and exhibits normal muscle tone.  despite respiratory depression, was alert and conversive with medical staff.  GCS to 14.  They admit him to monitor, placed on 2L for comfort, never had true hypoxia.  Toxicology consulted calling it Opiate Toxicity.  Only the ICU physician called it toxic encephalopathy but no where else in the record for the two day admission is that term used again or in the discharge summary.

    Some of our physician believe any AMS due to overdose or intoxication is automatically a toxic encephalopathy.

    Please share your thoughts on differentiating between someone with AMS due to alcohol or due to drugs using Poisoning and Toxic Encephalopathy.  Does an overdose automatically mean patient has a Toxic Encephalopathy?  What other clinical indicators do you look for with a Toxic Encephalopathy other than an altered mental status due to intoxication or overdose?

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited July 2018

    Re:  Encephalopathy with GCS of 14?


     Certainly I am not a Neurologist, but have read various articles and attended seminars in which the clinician instructing the course stated that encephalopathy was supported with GCS score of "8' or less.  


    Re: Meningitis with Encephalopathy; repeating I am not a Neurologist, but in my reading, I can find so clinical statement that 'Encephalopathy' is inherent to Meningitis.   AMS is not the same as true encephalopathy.  We know encephalopathy 'can be caused' by infections.  There is nothing in coding conventions that states we may not code encephalopathy, if present, supported and documented as due to infection.  I believe the denial is improper. One tenant of coding is that we need to use as many codes as applicable in order to report the clinical truth, and I code both when present.  


    Paul Evans, CCDS

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Also, there is an excellent ACDIS White Paper on this complicated topic you may wish to review?  It is very helpful. 
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    dbeiseldenton said:

    I would like to piggyback behind this question with another related question.  We see many patients that come to our ED intoxicated or overdosed on some drug.  In the ED, they describe the patients as sleepy but awake and talking, answering questions, he opens his eyes when his name is called.  Neurology exam states patient is alert and exhibits normal muscle tone.  despite respiratory depression, was alert and conversive with medical staff.  GCS to 14.  They admit him to monitor, placed on 2L for comfort, never had true hypoxia.  Toxicology consulted calling it Opiate Toxicity.  Only the ICU physician called it toxic encephalopathy but no where else in the record for the two day admission is that term used again or in the discharge summary.

    Some of our physician believe any AMS due to overdose or intoxication is automatically a toxic encephalopathy.

    Please share your thoughts on differentiating between someone with AMS due to alcohol or due to drugs using Poisoning and Toxic Encephalopathy.  Does an overdose automatically mean patient has a Toxic Encephalopathy?  What other clinical indicators do you look for with a Toxic Encephalopathy other than an altered mental status due to intoxication or overdose?

    I don’’t endorse the concept that an overdosed patient ‘always’ has Encephalopathy- nor, do I endorse the concept it is inherent to meningitis.   Encephalopathy is a complicated clinical and coding issue, and I personally believe one should be very cautious about any  statement such as ‘all patients with XX always have YY”.

      I am averse to endorsing encephalopathy in patient the record describes as ‘awake, alert, oriented, speaking, or ambulating  w/o difficulty’ and with a GCS that is not supportive of a highly abnormal neurological status.  (Suggest validation)  But, when clinical indicators are supportive, and it is documented (or confirmed via query process), it may be coded in order to fully report the condition of the patient unless probhibited by the Tabular, Index or a particular reference in AHA.   So, I would code encephalopathy with meningitis, subject to above.   If clearly stated and supported with ETOH use, I’d coded it based on the merits of each case.  I have NOT researched advice in AHA as I respond.

    In the example in which this is noted only once and in which the conditions seems to lack support, I’d issue a ‘validation’ to the Atending of Record.

    I look for poor GCS scores in order to support, and also review notes of RN and MD staff in order to read descriptions of the patient’s neurological status supporting an acute change in mentation that improves rapidly with treatment of the underlying condition.  The White Paper referenced has much more information that I can site here from memory on my pad.

    On pad...excuse typos

    Paul Evans, RHIA, CCDS, CCS, CCS-P
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