Query for underlying cause of encephalopathy

littlebit_62703@yahoo.comlittlebit_62703@yahoo.com
in Clinical & Coding

Patient came in on 06/27  with Epilepsia Partialis Continua secondary to previous hemorrhagic stroke. On admission arrived on LEV 1500 bid, Vimpat 300 bid and VPA 750 bid. The DS states this: Pt. developed hyperammonemia and encephalopathy so Lactulose 20 mg TID started and VPA was decreased back to 750 mg BID on 7/1. He continued to be mildly confused so VPA further decreased to 500mg BID on 7/2 and then stopped on 7/3. LEV decreased to 1000mg BID on 7/3---------------------Ammonia in normal range on 7/5 with mental status improving, although remains mildly confused with date and time. The physician never linked the cause of the encephalopathy. Wouldn't you have to query for the underlying cause?

Thanks,

Comments

  • littlebit_62703@yahoo.comlittlebit_62703@yahoo.com
    Never mind. the CDI on case wants an explanation as to why we need to query. I am letting the CDIS know that the coder cannot assume the etiology Thanks
  • lprescott1lprescott1
    I teach that if encephalopathy is present- the etiology should ALWAYS be identified. You cannot treat the condition without addressing the underlying issue. If it is mulitfactorial or the etiology cannot be determined then I query for the most likely source or sources.
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