Encephalopathy due to CVA

dbeiseldentondbeiseldenton
in CDI Talk Archive
The debate about the term "encephalopathy" just doesn't ever seem to go away. At a coding and CDI meeting today the discussion about encephalopathy came up because of all the denials this neurology hospital is getting when the Principal diagnosis is CVA with encephalopathy coded as a secondary condition.

Some of the coders that have been there a long time said they were taught by CDI's before that when the neurologist or attending documents Encephalopathy due to CVA that the encephalopathy is a residual effect and is coded because of the Coding Clinic that states current neurologic deficits treated during the admission; such as dysphagia, aphasia, confusion, cognitive deficits are reported. Others of us, felt that the term "encephalopathy" is a focused brain dysfunction integral to the stroke and should not be reported separately. Both sides of the table were so adamant that they were right and the other was wrong. Of course, the payors think that is wrong to code encephalopathy separately from the stroke, as well.

Please share your thoughts on this. Has anyone else ever heard of this before.

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I don’t think 'encephalopathy' in integral to a stroke. Certainly some stroke patients have AMS and some do not. However, in my understanding, 'encephalopathy' pertains to AMS due to something OUTSIDE the brain (electrolyte imbalance, hepatic, uremic, etc). Up-To-Date defines is as an acute condition of global dysfunction in the absence of structural brain damage. Therefore we do not query for encephalopathy on CVA patients (or seizure, concussion, tumors, etc) and instead look for cerebral edema or related issues.

    I still refer to this 'white paper' though it is from 2009.
    http://www.hcpro.com/content/235239.pdf


    That being said, our neurologist DOES use encephalopathy in CVA patients. We don’t question that and it is coded if she documents it. Also, I recently attended the I-10 CDI Bootcamp and they said it was an appropriate dx for CVA patients and not integral....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • dbeiseldentondbeiseldenton
    edited April 2016
    Hi Katy,

    Thank you for responding, I always appreciate your perspective. Please bear with me, this topic is still very confusing to me with differing opinions. Since "encephalopathy" is defined as an acute condition of global dysfunction in the absence of structural brain damage, therefore, you would not query for encephalopathy on CVA patients but instead would look for other related conditions such as cerebral edema BUT if the neurologist DOES document it you don't question it and the coder codes it.

    If a stroke is considered to be a focused structural brain damage doesn't this disqualify it then from being considered an "encephopathy". At least this is the rationale of the external reviewers who are denying it.

    Also, if the CDI's make the connection and do not query for it but also don't question the physician to confirm clinical validity and treatment then the coder reports it, I'm just wondering if you know they your hospital is getting denials like we are. I'm just curious.

    Thanks,

    Deb
  • catladyrncatladyrn
    I agree with the definitions Katy cites. The three keys for me that distinguish mental status changes in CVA from those of encephalopathy are that encephalopathy, as Katy states, is caused by a process outside the brain, that it is a functional rather than a structural abnormality, and that it is potentially reversible if the underlying cause is treated. Many of the changes in cognition associated with a CVA are permanent or at least only somewhat subject to improvement through rehab.

    I have never seen a neurologist attribute MS changes with a CVA to encephalopathy, but I'd be curious to hear their rationale as they undoubtedly would have an interesting explanation. As far as what they may have said in boot camp, I don't think the issue is whether encephalopathy is integral to CVA, but whether mental status changes associated with CVA also fit the definition of encephalopathy.

    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
  • lconaway@altoonaregional.orglconaway@altoonaregional.org
    edited April 2016
    We sometimes query for metabolic encephalopathy in certain CVA patients and our Neurologists will readily document this in most cases. Since stroke pts often having accompanying metabolic derangements that are treated with subsequent improvement in mental status, we ask. There is almost always an underlying cause for encephalopathy and in Coding Clinic 2003 Q4 p58, cerebral infarction is actually listed as a potential underlying cause for metabolic encephalopathy. It is not always appropriate to ask but we don’t exclude encephalopathy in a pt with a change in mental status simply because they present with a CVA.



    Metabolic Encephalopathy

    Coding Clinic 4th Quarter, 2003, p58

    Prior to October 1, 2003, several types of encephalopathy were all coded to 348.3, Encephalopathy, unspecified. New codes have been created to uniquely identify metabolic encephalopathy (348.31). Prior to this change, metabolic encephalopathy was indexed to delirium and coded to category 293, Transient organic psychotic conditions.

    Metabolic encephalopathy is always due to an underlying cause. There are many causes of metabolic encephalopathy, such as brain tumors, brain metastasis, cerebral infarction or hemorrhage, cerebral ischemia, uremia, poisoning, systemic infection, etc. Metabolic encephalopathy is also a common finding in 12-33% of patients suffering from multiple organ failure. The development of metabolic encephalopathy may be the first manifestation of a critical systemic illness and may be caused by various reasons--one of the most important being sepsis.



    I think the most important thing is to evaluate each medical record and determine if there is a direct relationship to the treatment rendered and the improvement in mental status. We have our Neurologists add clinical support when they document encephalopathy in CVA patients in order to make it RAC proof.



    LeeAnn Conaway, RN III, CCRN, CCDS
    CDS Coordinator
    UPMC Altoona
    Quality Management
    814–889–3313 office
    814–502-6772 cell






  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Deb,
    LeAnn has identified the reason if we have a dx made by the neurologist, we don’t question it. Our neurologist has explained to us that often encephalopathy post-stroke is not due to the damage to the brain itself but related to other metabolic issues. As these issues resolve, there should be improvement in the encephalopathy. Our neurologist is pretty good about documenting it when appropriate and since we (CDI) generally are not sure whether AMS is related to stroke or some other non-structural issue on this patient, we generally don’t query for it (unless there are extenuating circumstances that make us feel comfortable querying).

    Encephalopathy certainly is a ‘high-risk’ denial dx but we have not seen a high volume of denials on stroke patients when the neuro documents it independently.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • dbeiseldentondbeiseldenton
    That's good to hear. I'm guessing your documentation is very good and audit proof to ensure the clinical picture is adequatedly documented and treatment justified in the record.

    Thanks for all your input. I really appreciate it.

    Deb
  • aghacl2@yahoo.comaghacl2@yahoo.com
    Proper coding of Encephalopathy requires specificity. I think the best approach will be to look at this quagmire from two perspectives:

    1. Post-CVA encephalopathy is not going to be reimbursed: this is because it has apparently been discontinued in medical literature. 
    2. However, because encephalopathy is described as due to alteration in structure or function, we can obtain this important secondary diagnosis by carefully wording our queries: here, a patient with chronic encephalopathy no matter how subtle probably has some anoxic brain damage. Several neurones would have died, which is what you see in an MRI post-CVA. Reading the ACDIS pocket guide, you see that hypoxic encephalopathy refers to permanent brain damage, which comes with chronically altered mental status. When posed to the provider this way, care must be taken to avoid implying a cause-and-effect r/ship with the prior stroke. You should then obtain your diagnosis of hypoxic encephalopathy and conclude dry-shod. 

    Dr Agha,
    CDI Manager, 
    Rehoboth McKinley Christian Healthcare Center Services
    O: 505-8637063
    Cell: 662-3367706
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