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Documentation tips: Type of encephalopathy needed

24 Apr 2022

Cause is not enough to code and bill diagnosis

By: Dawn Gille RN, BSN, CCDS, CDS II, clinical documentation integrity

Have you found yourself asking, “Why am I still being queried for type of Encephalopathy when I documented the cause?”

The cause of encephalopathy is not enough information to code and bill this diagnosis. The type of encephalopathy is always required for coding.

The etiology of encephalopathy should be linked when known. For example: Your patient is admitted with encephalopathy and a UTI. 

Don’t document encephalopathy due to UTI. If you do not include the term metabolic it will code to “other encephalopathy” which does not accurately capture patient acuity.

Do document acute metabolic encephalopathy due to UTI

Types of Encephalopathy include:

Metabolic, Toxic, Toxic-Metabolic, Septic, Hepatic, Hypertensive, Hypoxic/Anoxic, Hypoxic Ischemic (applies only to neonates), Hypoglycemic, Traumatic, and Neonatal.

Traumatic (post-concussional) requires provider documentation of the type/cause/etiology, e.g., concussion, cerebral edema, brain compression, hemorrhage. This will code to the injury in most cases, not to the traumatic encephalopathy.

It is especially important to clearly state when a patient has acute encephalopathy in the setting of a chronic encephalopathy. For example, acute toxic encephalopathy secondary to medications in the setting of chronic hepatic encephalopathy.