Health Information Management

Q&A: Clarification for encephalopathy

CDI Strategies, September 27, 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 patient 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?

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 coders 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, Wis. Contact her at ssafian@embarqmail.com. This Q&A was originally published on JustCoding.



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