Health Information Management

Q&A: Querying for acute confusion

HIM-HIPAA Insider, January 17, 2012

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Q: Can a patient have encephalopathy after surgery? For example, a patient post-surgery becomes confused and is transferred from the medical-surgical floor to the intensive care unit and receives high doses of pain medication via IV. However, the patient recovers well and the confusion disappears after the IV fluids and reduction in pain medication and oxygen. Would a physician query be appropriate or would this be a red flag for auditors? The situation did extend the patient’s length of stay by one day.

A: I wouldn’t necessarily query for encephalopathy in this situation. However, I might ask whether the patient had “acute confusion” or “acute drug-induced delirium and/or hypoxia due to narcotics,” and I would want the physician to clearly link the condition to the underlying cause.

When an altered mental state is caused by a reversible cause (e.g., drugs), this is what we should report. The situation you describe sounds more like an adverse effect of medications then encephalopathy. Report an adverse effect by coding the condition (e.g., confusion, delirium, somnolence) along with an additional code (E935.2, Other opiates and related narcotic: Codeine [methylmorphine], Morphine, Opium [alkaloids], Meperidine [pethidine]) and indicating the adverse effect of the drug.

Reporting encephalopathy as the only MC could trigger an audit. Assigning the most appropriate description (e.g., confusion, delirium, hypoxia) as the adverse effect ensuring that the documentation clearly links the condition and the cause is important. Then the record is clear.

Editor’s note: Lynne Spryszak, RN, CCDS, CPC-A, an AHIMA-approved ICD-10-CM/PCS trainer and CDI education director for HCPro, Inc., in Danvers, MA, answered this question, which first appeared in CDI Strategies.

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