Health Information Management

Tools and tips: Refresh awareness of altered mental state documentation

CDI Strategies, December 10, 2009

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Physicians often default to the nonspecific term of altered mental status (AMS) (780.97) when describing psychiatric aspects of medical illness. Unfortunately, AMS is a generic symptom, which, if characterized with more specific terminology such as delirium, dementia, psychosis, stupor, or coma, can add relative weight in the various DRG methodologies, says James Kennedy, MD, CCS, of FTI Healthcare, in Atlanta, in the ACDIS White Paper “Cut through the confusion of altered mental status.”
 
In an informal ACDIS poll earlier this year CDI specialists answered the question: How well do your physicians document encephalopathy? 54% of 124 people who responded said physicians did not document encephalopathy in the chart when it was clinically present or only documented it after receiving a query. Responses included:
  • 44% Very well/requires few queries
  • 37% They will, but only upon query or request for clarification
  • 17% They typically do not use this term/we rarely report this diagnosis
  • 2% Not sure
If physicians in your hospital document AMS and rarely or never describe its underlying cause, you must provide education. Teach physicians that AMS is a nonspecific symptom.
 
“It’s not wrong to say to the physician, ‘That’s only a symptom code,’” Kennedy says.

Kennedy also offers a sample encephalopathy query form in the Forms & Tools Library on the ACDIS Web site. (Go to Forms & Tools, press control “F” and type in encephalopathy.)

The form illustrates the importance of not only documenting the nature and chronic level of the patient’s altered state but also the underlying causes in order to arrive at a more specific diagnosis, such as encephalopathy. Kennedy designed to comply with the recommendations of the American Health Information Management Association (AHIMA).



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