Encephalopathy is not a single disease but a disorder of cellular metabolism. Whether it is a lack of oxygen, a chemical imbalance, a metabolic dysfunction, dysregulation, or a toxic environment, the brain cells cannot function, leading to neurological symptoms.
Although most cases are temporary, the capture of encephalopathy is critical for documentation accuracy and to capture the complexity of the patient’s encounter. To accurately translate cases involving this diagnosis into coding and avoid cumbersome denials, coders and CDI specialists must thoroughly understand what to look for in clinical documentation. Physicians can help by using precise and codable terminology in their documentation.
Unraveling a diagnosis such as encephalopathy can be a daunting task due to the numerous types and the many twists and turns it can take clinically. I’ve outlined five core concepts to help anyone navigate the complexity of an encephalopathy case.
5 Types of Encephalopathy
- Metabolic Encephalopathy is an acute condition arising from a metabolic disturbance within the body that alters mental status.
- Toxic Encephalopathy can appear as a result of a reaction from a prescribed medication, illicit drugs, over-the-counter drugs, or a toxin such as vapors or toxic solutions and is also considered an acute condition.
- Hepatic Encephalopathy arises from a form of liver dysfunction such as cirrhosis or hepatitis. It is usually accompanied by an elevated ammonia level, which is often responsible for the acute alteration of mental status.The other scenario that can occur is when a patient has a progression of their underlying liver disease, resulting in an acute alteration of mental status that is remedied by increasing specific medication regimens.
- Hypertensive Encephalopathy occurs as a result of an acute hypertensive episode and can serve as an end-organ dysfunction in a hypertensive emergency or crisis.
- Static Encephalopathy is a chronic permanent state of a patient suffering from chronic epilepsy. This is not to be confused with transient (acute) alteration in mental status (AMS) during the post-ictal state that follows seizure activity, as this is considered integral to the seizure.
Acute forms of encephalopathy occur more frequently than chronic. There are numerous terms used in medical documentation for an encephalopathic process. Still, one should also consider coding rules, clinical symptoms, and regulatory enforcement of clinical validation, which comes from the False Claims Act, meaning that there must be sufficient clinical indicators to support billing for any encephalopathy.
5 Key Concepts for Navigating Encephalopathy Documentation
- Encephalopathy is diffuse by nature.
Per the National Institute of Neurological Disorders and Stroke, Encephalopathy is considered a ‘diffuse’ condition, indicating that the problem occurs as a widespread pathology within the brain that can’t be pinpointed.
- Imaging results are expected to be negative.
Because encephalopathy is defined as a diffuse condition, an abnormality should not be identified on imaging via CT scan or MRI.
One exception we must consider is the AHA Coding Clinic fourth quarter, 2018, page 16, which states that encephalopathy can be due to a cerebrovascular accident (CVA). CVAs are identifiable on imaging except for embolic showers, which require more time to build up the density needed to be identified on a head CT scan or MRI. Although this coding clinic’s direction appears to be the opposite of the medical definition, we cannot ignore the AHA Coding Clinic.
Many interpret it as: If the symptoms are due to direct damage (i.e. dysarthria due to fronto/temporal stroke) encephalopathy is not appropriate. However, global diffuse altered mental status due to the general dysfunction of the steady state of the brain, which dissipates after time and treatment, may be captured as encephalopathy.
- Identifying the cause is necessary.
Encephalopathy is always due to an underlying etiology, so the next step after imaging is to follow working differentials to identify the underlying cause.
- The underlying etiology must improve with treatment.
Once the underlying etiology is identified, the next step is to determine if the treatment for the underlying etiology improves the encephalopathic process that resulted in an altered mental state.
If the patient’s alteration in mental status (AMS) does not improve once treatment for the underlying condition is implemented, there are two possibilities. Either the underlying etiology is incorrect, and the treating providers must return to the drawing board and work up the clinical differentials again, or the patient doesn’t have encephalopathy, and something else is happening.
- The patient must return to mental status baseline.
The last core concept is that if the patient’s mental status has improved once treatment for the underlying cause was treated, the patient should return to their normal mental status baseline.
When a patient with dementia is admitted for AMS, a dementia baseline should be documented to allow for a CDI specialist to measure the patient’s return to baseline. This core concept is the clinical validating piece that supports the diagnosis of whichever type of acute encephalopathy is being addressed.
Conundrum Cases
I can’t speak about encephalopathy without addressing a few twists and turns that make this diagnosis challenging to capture accurately.
One particularly challenging scenario is when a patient with dementia is admitted with an alteration in mental status. Often, the patient resides in a nursing home and wakes up altered, making it necessary to transport the patient to the emergency room, where a UTI is identified. For this class of patients, the only way to measure the return to baseline is to have a documented mental status baseline for dementia.
Another problematic scenario is when two different forms of encephalopathy are superimposed on each other. This gets tricky as one would need to identify an underlying etiology for each one to validate the diagnoses clinically.
Conclusion and Additional Resources
Regardless of the scenario, if the five core concepts outlined above are considered, along with referring to applicable AHA coding clinics and coding conventions, processing these cases will be more straightforward. Accuity’s clinical capture experts have created this tip sheet as an additional support tool.
About the Author
With more than 30 years as a nurse, 25 years as a clinical educator, 10 years of CDI expertise, and 10 years as a legal nurse for medical bill auditing, Dawn Valdez, RN, CDIP, CCDS, CRC, joined the Accuity team in 2023 as Senior Director, CDI Services. In this role, Dawn develops and provides ongoing education for Accuity’s team of CDI specialists. As an expert voice in the CDI landscape, Dawn presents educational content at regional and national industry conferences, including AHIMA and ACDIS state chapters.
Before joining Accuity, Dawn contributed as a volunteer for many ACDIS-related projects and worked as an education specialist for the ACDIS organization for 3.5 years. Dawn has also authored numerous CDI-related articles for ACDIS-CDI Strategies, ACDIS-CDI Journal, and ICD-10 Monitor, and authored the 3rd volume of the CDI Specialist Training Guide, re-designed for emphasis on the new CDI Specialist while serving simultaneously as a refresher for experienced CDI specialists.