Health Information Management

Q&A: Coding for acute mental status change secondary to an infectious process

JustCoding News: Inpatient, September 12, 2012

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Q: I need further clarification regarding documentation of toxic metabolic encephalopathy. I’m trying to code two different cases in which a physician documents acute mental status change secondary to an infectious process. In each case, the patient’s metabolic panels don’t appear to be abnormal; however, one of the patients is septic. The physician thinks that documenting and coding sepsis separately from encephalopathy would result in unbundling. However, I disagree because coding the sepsis separately demonstrates severity. What is the correct logic to use in each of these cases?

 
A: To answer your questions, I’m going to discuss each of the two patient’s cases separately.
 
The first patient has acute mental status change secondary to an infectious process with a normal metabolic panel.Based on the information you’ve provided, ICD-9-CM code 349.82 (toxic [metabolic] encephalopathy) accurately represents the patient’s documented condition.
 
According to the National Institute of Neurological Disorders and Stroke, an altered mental state is an inclusive sign of encephalopathy. Therefore, coders shouldn’t report it separately. ICD-9-CM code 780.97 (altered mental status) includes an Excludes note that directs code to code to condition for an altered mental status due to a known condition.
 
The second patient also has acute mental status change secondary to an infectious process with a normal metabolic panel; however, he or she has sepsis as well. The physician is required to document all details about the patient’s condition, including his or her sepsis. However, documentation of the term sepsis is irrelevant in this case because ICD-9-CM code 348.31 (septic encephalopathy) most accurately describes the patient’s condition.
 
Note that there is a difference between metabolic (septic) encephalopathy and toxic (metabolic) encephalopathy as identified by the cause of the condition. Metabolic (septic) encephalopathy is a diffused brain disease affecting the patient’s brain structure and function. This condition is due to metabolic dysfunction, a neoplasm in the brain, or another physiological event. Toxic metabolic encephalopathy is a reaction to a toxic substance. ICD-9-CM code 349.82 requires an additional E code to report the specific toxin.
           
Editor’s note: Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor teaching medical billing and insurance coding at Herzing University
Online in Milwaukee, WI. You can reach her at ssafian@embarqmail.com.
 
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
 
Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.



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