Encephalopathy is a broad term that describes abnormal brain function or structure that can lead to an altered mental status, leaving the patient confused and not acting like they usually do. It can happen when there's been a change in the way the brain works or a change in the body that affects the brain. Due to its prevalence, it is common that it arises as a condition that requires proper medical coding
There are many types of encephalopathy, including metabolic, toxic, anoxic, hypertensive, and Wernicke's encephalopathy. To accurately code and identify clinical documentation improvement opportunities for encephalopathy, it is crucial to understand the characteristics of the different types. For instance, metabolic encephalopathy is caused by a buildup of toxins in the body, whereas toxic encephalopathy is caused by exposure to toxic chemical substances. Anoxic encephalopathy occurs when the brain is deprived of oxygen, while hypertensive encephalopathy is caused by high blood pressure. Wernicke's encephalopathy is a type of brain injury most common in those who drink alcohol excessively, which causes a lack of thiamine, a type of vitamin B.
| Type | ICD-10-CM Code |
| Hypertensive encephalopathy | I67.4 |
| Toxic encephalopathy | G92.8 (other toxic encephalopathy) G92.9 (unspecified toxic encephalopathy) |
| Metabolic encephalopathy and encephalopathy septic | G93.41 |
| Anoxic encephalopathy | G93.1 |
| Wernicke's encephalopathy | E51.2 |
Medical coders must also understand the specific symptoms associated with each type. For instance, symptoms of metabolic encephalopathy include confusion, lethargy, and seizures, while symptoms of toxic encephalopathy include tremors, muscle weakness, and loss of consciousness. Symptoms of anoxic encephalopathy include memory loss, confusion, and seizures, while symptoms of hypertensive encephalopathy include headache, nausea, and vomiting. Symptoms of Wernicke's encephalopathy include confusion, ataxia, and vision changes.
There are differences medical coders need to understand between acute versus chronic encephalopathy. Coding and documentation improvement challenges can arise when encephalopathy is documented alongside conditions such as a patient with dementia, a patient involved in a cerebrovascular accident (CVA), or patients with specific conditions such as urinary tract infection, hypoglycemia, or sepsis. There are also differences to note related to poisoning and adverse effects as well as alcohol use.
In addition to understanding the different types and symptoms of encephalopathy, medical coders must be aware of the query opportunities and coding clinics surrounding this condition. It is important to work closely with physicians and patients to determine with specificity the cause and duration of encephalopathy. The documentation should include information such as when the diagnosis started, when the symptoms started, and how long the symptoms have lasted.
Accurate medical coding is critical for proper documentation and treatment of encephalopathy. Medical coders must have a thorough understanding of the different types and symptoms of encephalopathy, as well as the official coding resources and guidelines. Contact us for more information about supporting your team with our medical coding services, technology, and software related to code updates and guidelines.
Author
