Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Encephalopathy and Brain-Related SOI Cindy Pritchett, RN, BSN, CCDS CD Consultant MedPartners HIM Tampa, Fla. "Image courtesy of Victor Habbick/FreeDigitalPhotos.net" Learning Objectives Patient Presentation • Explain types and causes of encephalopathy • • • • • • • • • 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 3 2 Confused Disoriented Memory loss W k Weakness/numbness / b Poor coordination Lethargic Delirious “ALTERED MENTAL STATUS” Combative Psychotic "Image courtesy of cooldesign/FreeDigitalPhotos.net" ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 4 1 Differential Diagnoses • • • • TIA vs. CVA Infection Injury Progression of chronic disease • Toxic effects • Dehydration • Fluid/electrolyte imbalances • • • • Coding Guideline Changes CT head Labs/cultures MRI/MRA brain EEG 2003 348.30 Encephalopathy, unspecified moved from being indexed to delirium • 348.31 Metabolic encephalopathy 2008 MS-DRGs • • 348.39 Other encephalopathy – Excludes • alcoholic (291.2) • hepatic (572.2) • hypertensive (437.2) • "Image courtesy of Stuart Miles/FreeDigitalPhotos.net" MCCs – – includes septic – Excludes toxic metabolic (349.82) • Tiered severity • All encephalopathies excluding CCs CCs – – – Alcoholic Anoxic Hypertensive 349.82 Toxic metabolic encephalopathy 5 6 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 7 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 2 “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 "Image courtesy of digitalart/FreeDigitalPhotos.net" 10 Potential Causes • • • • • • • • Severe hyponatremia Respiratory failure Severe sepsis Intracranial bleed Acute alcoholism Status epilepticus Zinc deficiency Drug overdose Encephalopathy Types • • • • • • • • • • • • • 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) "Image courtesy of ddpavumba/FreeDigitalPhotos.net" 11 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 12 3 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) "Image courtesy of Renjith Krishnan/FreeDigitalPhotos.net" 13 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) ( ) 14 • 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 "Image courtesy of digitalart/FreeDigitalPhotos.net" "Image courtesy of SheelaMohan/FreeDigitalPhotos.net" 15 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 16 4 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 "Image courtesy of cooldesign/FreeDigitalPhotos.net" "Image courtesy of koratmember/FreeDigitalPhotos.net" 17 Additional Encephalopathy Types Ischemic (MCC) • Narrowing vessels limiting blood supply to brain – Progressive loss of function weakness, AMS 18 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 "Image courtesy of Salvatore Vuono/FreeDigitalPhotos.net" 19 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 20 5 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 • • • • • • • 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 • • • • • • 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 21 Query Possibilities • • • • 22 Clinical Indicators Case #1 • • • • 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?) 23 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 24 6 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: ______________________ 25 26 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 • • • • • • • • 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 27 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 28 7 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 • • • • 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) 29 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. • • • • • 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 30 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 31 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 32 8 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 • • • • • • • Gross ascites Elevated LFTs Elevated ammonia Treatment • • • • • 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 33 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 • • • • • 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 • • • • IV ABX IV Steroids Resp RX 34 agitation after extubation x 72 hrs • Creatinine 1.2 • Oral Steroids Metabolic encephalopathy (MCC) or Hypoxic encephalopathy (CC)? NS bolus x 2 liters 35 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 36 9 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 • • • • • • • 37 Clinical Indicators Case #7 • • • • • 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 38 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 39 "Image courtesy of ddpavumba / FreeDigitalPhotos.net" ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 40 10 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 • • • • • • 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 41 ICD-10: Encephalopathy Expanded • hypoxic – see Damage, brain, • • • • • • • • 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 • • • • • • • • • 42 • 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 • • • • • • • • • • • • 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 43 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 44 11 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. 45 46 Thank you. Questions? [email protected] In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook. 47 ©2013 HCPro, Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro, Inc. For questions please contact HCPro customer service at 800-650-6787. 12