Download 1 Learning Objectives Patient Presentation

Encephalopathy
and Brain-Related SOI
Cindy Pritchett, RN, BSN, CCDS
CD Consultant
MedPartners HIM
Tampa, Fla.
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Learning Objectives
Patient Presentation
• Explain types and causes of encephalopathy
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and typical physician terminology
• Describe common scenarios and opportunities
for encephalopathy and brain-related
brain related severity of
illness queries, as well as potential compliance
risks and RAC targets
• Apply lessons learned to case scenarios
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Confused
Disoriented
Memory loss
W k
Weakness/numbness
/
b
Poor coordination
Lethargic
Delirious
“ALTERED MENTAL STATUS”
Combative
Psychotic
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Differential Diagnoses
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TIA vs. CVA
Infection
Injury
Progression of chronic
disease
• Toxic effects
• Dehydration
• Fluid/electrolyte
imbalances
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Coding Guideline Changes
CT head
Labs/cultures
MRI/MRA brain
EEG
2003
348.30 Encephalopathy,
unspecified moved from
being indexed to delirium
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348.31 Metabolic encephalopathy
2008
MS-DRGs
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348.39 Other encephalopathy
– Excludes
• alcoholic (291.2)
• hepatic (572.2)
• hypertensive (437.2)
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MCCs
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– includes septic
– Excludes toxic metabolic (349.82)
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Tiered severity
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All encephalopathies
excluding CCs
CCs
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–
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Alcoholic
Anoxic
Hypertensive
349.82 Toxic metabolic
encephalopathy
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Terminology
“Hospital/ICU Psychosis”
• Confusion: inability to maintain a coherent stream of
• Result of organic stress on the central nervous
thought or action
• Delirium: confused state with superimposed
hyperactivity of the sympathetic limb of the
autonomic
t
i nervous system
t
system rather than the factors in ICU/hospital
setting
• Carries
C i SOI if documented
d
t d appropriately
i t l
– Tremors, tachycardia, diaphoresis, mydriasis
– Primarily associated with psychiatric conditions
• Equals toxic metabolic encephalopathy
unrelated to underlying systemic conditions
• Requires physician education
• Encephalopathy: diffuse disease of the brain that
alters brain function or structure
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“Sundowning”
Study Shows …
• Baseline mental status with patterned
• Delirium occurs in as many as 56% of hospitalized pts
• Delirium occurs in 20-79% of hospitalized older pts
impairment occurring at dusk – returns to
baseline every morning
• What happens
pp
when “Sundowner” receives
medication worsening baseline & “Sundowning”
episodes?
TOXIC METABOLIC ENCEPHALOPATHY
– Can progress to psychosis with hallucinations
– Can take SEVERAL days to improve after meds
- One study reported it to be present upon admission
to ICU in 31% of pts > 65
• D
Delirium
li i
occurs iin 20
20-50%
50% off non-vented
t d ICU pts
t
• Delirium occurs in 60-80% of vented ICU pts
• Metabolic encephalopathy present
in 12-33% of patients
with organ failure
discontinued and discharge delayed
– Sitters/restraints required
CC 4th Q 2003, p. 58-59
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Potential Causes
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Severe hyponatremia
Respiratory failure
Severe sepsis
Intracranial bleed
Acute alcoholism
Status epilepticus
Zinc deficiency
Drug overdose
Encephalopathy Types
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Hypoglycemia
Postictal
CNS sepsis
Delirium tremens
Hepato-lenticular
degeneration (Wilson’s
disease)
• Functional psychoses
Toxic metabolic (349.82)
Infectious/septic (348.31)
Alcoholic (291.2)
H
Hepatic
ti (572.2)
Hypertensive (437.2)
Hypotensive (348.39)
Structural (348.39)
Anoxic (348.39)
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Metabolic Encephalopathy (348.31)
Septic (348.31) / Infectious (348.39)
Definition
Possible causes
Definition
Possible causes
• An acute condition of
• Impaired organs
• AMS in presence of
• Underlying
global cerebral
dysfunction in the
absence of primary
structural brain disease
• Encompasses delirium
and the acute
confusional state
infection
• Same ICD-9 code as
metabolic
encephalopathy
• Liver (hepatic)
• Kidney (uremic)
• Thyroid (Hashimoto’s)
• Abnormalities of water,
vitamins, chemicals,
electrolytes (sodium,
infection/septic state
glucose)
(CC, 4th Q 1993, p. 29)
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PDX Sequencing – RAC Target
Toxic Metabolic Encephalopathy (348.92)
Definition
Possible causes
• Brain tissue
• CO2 toxicity
• Poisoning
• Drug ingestions/toxicity
degeneration due to
toxic substance(s)
( )
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• Alcoholic liver cirrhosis vs. hepatic enceph
• AHA Coding Clinic, First Qtr 2002
– Advised coders to assign the
hepatic enceph as the PDx
(outside agents)
– Could the patient stay at home
with the condition?
• Yes to cirrhosis –
no to encephalopathy
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Additional Encephalopathy Types
Alcoholic (CC)
Wernicke-Korsakoff
Additional Encephalopathy Types
Anoxic (CC)
Hypertensive (CC)
Hypotensive (MCC)
Global loss of brain
function (time = tissue)
HA, N/V, visual changes,
decreased LOC
Bleeding, major
infections, BP meds
B1 deficiency
• s/p CPR,
CPR prolonged
• Hypertensive
H
i
• Symptoms
S
fainting,
f i i
• Nonreversible
seizures, prolonged
status asthmaticus,
prolonged COPD
exacerbation
• Due to malnutrition –
crisis/emergency
• BP elevation w/ organ failure
• Also see chest pain, SOB, RF
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Additional Encephalopathy Types
Ischemic (MCC)
• Narrowing vessels
limiting blood supply
to brain
– Progressive loss of
function
weakness, AMS
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Encephalopathy With Coma
Coma is one of the four grades of encephalopathy
Structural (MCC)
• Head trauma
– Grade I: confusion or AMS
– Grade II: somnolence, inappropriate behavior, impending
(internal or external)
I
d ICP
– Increased
• Bleed/stroke
– Grade III: stuporous but arousable,
arousable markedly confused
stupor
behavior
– Grade IV: unresponsive, coma
• Exception: Hepatic encephalopathy (coma) is included in code assignment
at 4th digit level – not necessary to report 572.2, Hepatic coma, as additional
code assignment CC, First Quarter 1998, pp. 3-4
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CABG Postop
Case Review #1
• The reported incidence of postoperative
68 y/o male DM pt presents with sepsis secondary to UTI,
AMS, and profound hypotension.
encephalopathy varies from 8.4% to 32%
– Presentation more subtle
– Symptoms
y p
p
present following
g extubation
Presentation
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• Should suspect it earlier when patients emerge
combative or agitated from anesthesia
• Often delays extubation
– Increased LOS (avg 14 days vs. 8)
– Higher mortalities (7.5% – 3x the avg rate)
– Often require rehab
Lethargic
BP 68/42
HR 104
Resp 24
Temp 97.2
PCT 23.1
(procalcitonin)
Treatment
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ICU
Course of Stay
• Lethargic x 48
hrs then return
to baseline
NS x 2L ED
Dopamine gtt
Levophed gtt
BCX
• Vasopressors
off after 24 hrs
• 5-day stay
UCX
• WBC 28.2
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Query Possibilities
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Clinical Indicators Case #1
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Manifestation: presenting signs/symptoms
Hypotension
Sepsis diagnosis
WBC 28.2
AMS in presence of infection - lethargy x 48
hrs
• Age 68
Underlying: cause – “due to”
Severity: (acute or chronic)
Instigating cause: (e.g., if the encephalopathy
is due to a toxic substance, was the drug taken
as prescribed or was it an accidental overdose?)
• Consequences: (e.g., did the patient fall and
Infectious/Septic Encephalopathy
break a bone?)
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Sample Query “Question”
Sample Query “Reasonable Options”
Based on the above abnormal clinical findings, can
you specify the known or suspected type of altered
mental status status this patient was experiencing that
produced a lethargic (obtunded, confused, agitated,
comatose etc
comatose,
etc.)) state?
___Encephalopathy (specify type):
___Metabolic (MCC)
___Infectious/Septic (MCC)
___Hypertensive (CC) ___Alcoholic (CC)
___Anoxic (CC)
___Unspecified (MCC)
___Other: ______________________
___Dementia
(specify type):
(specify behavior):
___Senile
___Alzheimer’s ___Unspecified
___Delirium/Acute confusion (CC)
___with depression (NO CC)
___with delusion (NO CC)
___with behavioral disturbance (CC)
___Coma (MCC)
___Unable to determine
___Other: ______________________
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Case Review #2
Clinical Indicators Case #2
75/M with AMS found early morning by spouse at home.
Unable to speak – was “fine” at bedtime.
? Hypertensive Encephalopathy
• Accelerated HTN
• Decreased LOC POA
– Obtunded/lethargic X 48 hours
• Age 75
• BP 208/105 – IV Labetolol
Presentation
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Aphasia
Right-sided weakness
Vomitus on sheets
Lethargic
BP 208/105
HR 98
Resp 22
Afebrile
Treatment
• CT head
– Ischemic stroke
• Anticoagulation
• CXR – ? RLL
infiltrate
• IV Labetalol
• IV ABX
Course of Stay
• CXR – RLL
pneumonia
• Decrease LOC
– Obtunded/leth
argic
x 48 hrs
– Alert but
Likely normal evolution of CVA
disoriented
– Clear at d/c
Permissive HTN usually allowed in a CVA
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Case Review #3
Clinical Indicators Case #3
Pt s/p unwitnessed arrest down for unspecified time arrived
on vent with CPR in progress. To ICU after resuscitation x 2.
• S/P CPR
• Unresponsive w/o sedation
Presentation
• Afebrile –
hypothermia
protocol
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HR 86
RR 18 on vent
BP119/58
Unresponsive
w/o sedation
Treatment
• Focused
on cardio
pulmonary
status
• Critical care
• CT head after
– Obtunded/lethargic X 48 hours
Course of Stay
• Remained confused and disoriented after extubation
• Extubated
– slow to respond – no resolution
after 48 hrs
• Absence of infection
• BP stable
• No mention of electrolyte or metabolic imbalances
• Confused &
disoriented
• Slow to respond
extubation
neg for acute
changes
Anoxic vs. TME (secondary to anesthesia/meds)
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Warrants discussion/query
Case Review #4
Clinical Indicators Case #4
72 male pt with AV stenosis underwent open AVR with
postop AF/RVR requiring 3 ICU days.
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Presentation
• Alert –
oriented x 3
w/o hx
dementia
• VSS
• Infection-free
Treatment
• Surgical
procedure
• IV meds for rate/
rhythm control
• PCA pump
• Sleeping med
Course of Stay
• Confused ICU
day #2 – pulling
out lines
• Restraints applied
• Narcotics dc’d
• Mental status
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AMS – pulling out lines – restraints applied
Multiple new medications
Antiarrhythmics, pain meds, sleep meds
No s/s infection
Mental status improved after discontinuation of
medication(s)
Likely Post-op Drug-Induced Delirium (292.81)
with e-code indicating Adverse Drug Reaction
* Equals a CC, but reportable in HealthGrades
improved day
following med
changes
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Case Review #5
Clinical Indicators Case #5
Alcohol liver cirrhosis homeless patient unarousable at
shelter – moaning only. No further history.
• AMS – nonarousable followed by confused and
Presentation
• Weak,
Weak confused,
confused
combative
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Gross ascites
Elevated LFTs
Elevated ammonia
Treatment
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Lactulose
IVFs
Restraints
Low-dose Ativan
ETOH withdrawal
precautions
BP 148/72
HR 88
• Abd paracentesis
combative behavior requiring restraints
• History of alcoholic cirrhosis with elevated
Course of Stay
p
pneumonia
• Restraints off
• AMS resolved after 72 hours when LFTs
after 24 hours –
sitter required
improved
• A&O x 3 after
72 hours
• LFTs improved but
remained slightly
elevated
Resp 18
Temp 99.4
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Hepatic Encephalopathy
PDX? 3 day stay – Hepatic encephalopathy
5 day stay – Investigate further due to
DRG/LOS mismatch
Case Review #6
Clinical Indicators Case #6
92-year-old COPD nursing home pt found in respiratory
distress, confused, & agitated w/o hx of dementia
• Respiratory failure (PH < 7.35)
• Confused and agitated x 72 hours after
Presentation
• Rapidly progressed to
lethargy
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Treatment
PH 7.32
Resp 32
Temp 97.2
Creatinine 2.5 (no hx
CKD)
intubation/sedation
• AKI
• Resolved AMS – not permanent
Course of Stay
• ETT / Mech Vent
• Vent x 48 hrs
• Sedation to prevent • Confused w/o
RA sats 79%
self-extubation
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IV ABX
IV Steroids
Resp RX
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agitation after
extubation x 72 hrs
• Creatinine 1.2
• Oral Steroids
Metabolic encephalopathy (MCC) or
Hypoxic encephalopathy (CC)?
NS bolus x 2 liters
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What’s the Difference?
Hypoxic
Encephalopathy
(CC)
Case Review #7
Metabolic
Encephalopathy
due to Hypoxemia
(MCC)
Alcohol-dependent cirrhosis pt admitted with 3rd-degree
burn to back – found down > 6 hours.
Presentation
Treatment
Course of Stay
• Confused and
• Wound care
• Alcohol
• Full-blown
Full blown DTs
• One-day stay –
agitated
• Cause due to anoxic
• Cause due to
brain damage
• Irreversible/
Permanent
hypercapnea/
hypercabia,
hypoxia/hypoxemia
• Reversible/temporary
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Clinical Indicators Case #7
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BP 112/68
withdrawal
protocol
HR 84
transferred to
burn care center
• Low-dose
Resp 16
sedatives
Temp 97.6
Elevated BUN 36
Elevated CPK 432
Elevated ammonia
level 84
• Aggressive IVF
resuscitation
• Lactulose
• IV ABX
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Additional Brain SOI
Confused & agitated prior to arrival
Elevated ammonia levels
? Rhabdomyolysis
ETOH/DTs
Lactulose
CC
• Delirium - acute due to
condition classified elsewhere
• Dementia
e e t a with
t be
behavioral
a oa
disturbance
• Hallucinations other than
visual
What’s missing? WBCs, temp, infection indicators
MCC
• Cerebral/Vasogenic Edema
– check radiographic reports
for
o midline
d e sshiftt o
or ede
edema
a
– Mannitol, Steroids,
Decadron
• Coma
• Delusions associated with
paranoid schizophrenia
Hepatic encephalopathy vs. DTs vs.
septic/infectious encephalopathy
WHAT TO DO? QUERY
• Acquired Hydrocephalus
• Specified bipolar disorder
• Drug withdrawal
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Additional Brain – No SOI
ICD-10 – 10/1/2014
Are You Ready?
• Delirium – acute not
• Encephalopathy
(acute) G93.40
associated w/ any condition
• acute necrotizing hemorrhagic
• Dementia w/o behavioral
G04.30
disturbance
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• Stupor
St
• Psychosis
• Bipolar Disorder unspecified
• Seizure
postimmunization G04.32
postinfectious G04.31
specified NEC G04.39
• Confusion
NEC G32.89
• demyelinating callosal G37.1
• due to drugs – see also Table of
Drugs and Chemicals G92
• hepatic – see Failure
Failure, hepatic
• hyperbilirubinemic, newborn P57.9
• due to isoimmunization
alcoholic G31.2
anoxic – see Damage,
brain, anoxic
• arteriosclerotic I67.2
• centrolobar progressive (Schilder)
• Concussion
• degenerative, in specified disease
(conditions in P55) P57.0
• hypertensive I67.4
• hypoglycemic E16.2
G37.0
• congenital Q07.9
• Alzheimer’s with dementia
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ICD-10: Encephalopathy Expanded
• hypoxic – see Damage, brain,
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hypoxic ischemic P91.60
mild P91.61
moderate P91.62
severe P91.63
P91 63
in (due to) (with)
birth injury P11.1
hyperinsulinism E16.1
influenza – see Influenza, with,
encephalopathy
• lack of vitamin – see also
Deficiency, vitamin E56.9
• neoplastic disease (see also
ICD-10: Encephalopathy Expanded
• serum – see also Reaction, serum
anoxic
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•
•
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• drug induced G92
• toxic G92
• myoclonic, early,
T80.69
syphilis A52.17
trauma (postconcussional) F07.81
current injury – see Injury,
intracranial
vaccination
i ti G04.02
G04 02
lead – see Poisoning, lead
metabolic G93.41
drug induced G92
toxic G92
myoclonic, early,
symptomatic – see Epilepsy,
generalized,
specified NEC
symptomatic – see Epilepsy,
generalized,
specified NEC
• necrotizing, subacute (Leigh)
G31.82
• pellagrous E52
• portosystemic – see Failure,
hepatic
• postcontusional F07.81
• current injury – see Injury,
intracranial, diffuse
• posthypoglycemic (coma) E16.1
Neoplasm) D49.9
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•
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•
•
postradiation G93.89
saturnine – see Poisoning, lead
septic G93.41
specified NEC G93.49
spongioform, subacute (viral)
A81.09
toxic G92
metabolic G92
traumatic (postconcussional)
F07.81
current injury – see Injury,
intracranial
vitamin B deficiency NEC E53.9
vitamin B1 E51.2
Wernicke’s E51.2
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References
References
1. Murphy, Brian, CPC, Director ACDIS. Cut Through the Confusion of Altered Mental
7.
Chalela, Julio, MD; Kasner, Scott, MD. Acute Toxic-Metabolic Encephalopathy in
Adults. Retrieved December 30, 2012, from website Up To Date:
www.uptodate.com.
8.
Definition of Encephalopathy. Retrieved January 1, 2013, from MedicineNet.com
website: www.medterms.com/script/main/art.asp?articlekey=101343
9.
ICD10Data.com. ICD-10 Codes. Retrieved January
y 15, 2013, from website:
www.icd10data.com/Search.aspx?search=encephalopathy&
codebook=AllCodes
Status (White Paper). Retrieved December 30, 2012, from ACDIS website:
www.hcpro.com/content/235239.
2. Pinson, Richard D., MD, FACP, CCS; Tang, Cynthia L, RHIA, CCS. (2012) CDI
Pocket Guide (5th Edition). HCPro, Inc. Key Reference tab, pp. 8–9.
3. ACDIS. ((2012, Julyy 8)) Ensure compliance
p
when reporting
p
g cirrhosis and alcoholic
hepatitis with an MCC. Retrieved December 30, 2012, from ACDIS website:
www.hcpro.com/print/HOM-253543-5728, pp. 1–4.
4. J.A. Thomas. (2010, July 14) FHIMA Coding Round Table.
10. Foshight, Sue, BSPharm, BCPS, CGP. Delirium in the Elderly. Retrived
December 30, 2012 from website: www.acpp.com, page 73.
5. Journal of AHIMA, 2008 Audio Seminar Series 30 CPT Codes. (2012, March) RAC
11. Castillo, Luis; Bugedo, Guillermo; Paranhos, Jorge. (2009, June) Mannitol or
Inpatient Coding Denials, Copyright 2007 by AMA.
Hypertonic Solutions for Intracranial Hypertension? A Point
of View. Critical Care and Resuscitation 11(2):151–154.
6. Hunter, Shereen, MD. (no date referenced) Hepatic Encephalopathy. Retrieved
December 30, 2012, from website: www.med.cu.edu.eg.
7. Wedro, Benjamin, MD, FACEP, FAAE. Learn About Encephalopathy Causes,
Symptoms, Types, Treatment. Retrieved December 30, 2012, from website:
www.eMedicineHealth.com, pp. 1–12.
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