Encephalopathy: When Altered Mental Status Doesn’t Make …

Encephalopathy: When Altered Mental Status Doesn't Make Sense!

James P. Fee, MD, CCS, CCDS AHIMA-Approved ICD-10-CM/PCS Trainer Vice President Enjoin July 26, 2016

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Objectives:

? Define "altered mental status" in relation to confusion, delirium, and encephalopathy

? Provide clinical insights regarding the documentation and coding of encephalopathy

? Explore specific case examples with compliant query development

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Brain Games

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Why Doesn't It Make Sense?

? What is patient's baseline? ? Clinical diagnosis (no specific test) ? Terms used synonymously ? Lack of clear guidelines

Yet......

? 30% of hospitalized adults ? 20-40% mortality ? Heralding symptom of major illness ? 33% persist at 6 months

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Acute Confusional

State-CC

Post?operative Delirium - CC

Altered Mental Status

Delirium (drugs / med condition)-

CC

Coma ? MCC

Encephalopathy (type) MCC

Defining Altered Mental Status

? Altered Level of Consciousness (R40.x)

? Depressed consciousness only without disordered thinking or inattention

? Need specification of degree

? Coma (R40.2x) ? Stupor (R40.1)

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Coma: "Unarousable Unresponsiveness"

Glasgow Coma Scale

Spontaneous Response to verbal command Response to pain No eye opening

Oriented

Eye Opening Best Verbal Response

Confused Inappropriate words Incomprehensible sounds No verbal response

Obeys commands Localizing response to pain Withdrawal response to pain Flexion to pain Extension to pain No motor response TOTAL

Best Motor Response

Score

4 3 2 1

5

4 3 2 1

6 5 4 3 2 1

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Source: The Lancet 13;2 (7872): 81-84, 1974.

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Defining Altered Mental Status

Unspecified / Chronic Confusion (R41.0)

? Characterized by: ? Disordered thinking (slow and/or incoherent; perceptual abnormality) OR ? Inattention (inability to focus or shift attention)

? Specification: ? Acute: sudden change (i.e. hours to days) usually accompanied by altered level of consciousness ? Chronic: stable with very brief changes often found in structural, degenerative, or psychological disorders ? Acute on chronic

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Defining Altered Mental Status

"Acute confusional state" (R41.0)

? Characterized by: ? Acute state of altered consciousness (drowsy, stupor, coma) AND ? Disordered thinking (slow and/or incoherent) OR ? Inattention

? Delirium is often considered a type of acute confusional state

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Defining Altered Mental Status

Delirium

? Confusion Assessment Method (CAM)

1. Acute and fluctuating 2. Inattention (distracted, poor focus) 3. Disordered thought (incoherent, rambles) 4. Altered level of consciousness (hyper alert,

delusions, fantasies, agitated, lethargic, stupor, coma) ? Requires 1 and 2 AND either 3 or 4

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Defining Altered Mental Status

Delirium

? DSM-V characterized by: 1. Altered level of consciousness with inattention 2. Disordered thinking or perception that is not better accounted for by

a pre-existing or evolving neurocognitive disorder (dementia) or coma 3. Acute and fluctuating course over a short period of time 4. Evidence by history, physical examination, or laboratory findings that above caused by medical condition, substance intoxication, or medication side effect. ? Delirium may have associated behavioral disturbances (hypo or

hyper activity, etc.) and emotional disturbances (fear, euphoria)

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Clinical Case

Patient is admitted with nonoperable pelvic rim fractures and noted to have delirium in the emergency department. Patient was admitted for further evaluation of stroke/TIA which after study was ruled out. CT of the head was unremarkable. After study, can the patient's delirium be further specified as: ? Acute delirium due to fracture pain ? Delirium of unknown cause ? Other___________ ? Clinically undeterminable

February 2013 - "Guidelines for Achieving a Compliant Query Practice." Journal of AHIMA 84, no.2: 50-53. Multiple Choice Queries

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Clinical Case

78 WM with HTN, DM, and CAD admitted for chest pain. The patient was documented to have intermittent altered mental status during the hospital course. Head CT and electrolytes were normal. Patient had waxing /waning disorientation with periods of agitation associated with poor sleep. After study, can the altered mental status be further specified as: 1) Acute confusional state due to poor sleep 2) Acute delirium due to poor sleep 3) Chronic intermittent confusion 4) Acute delirium of unknown etiology 5) Other______________ 6) Clinically undetermined

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Clinical Case

Patient documented to have confusion and delirium in the postoperative period. Work up including head CT, medication review, and electrolyte evaluation as negative. The progress notes documented delirium improved. After study, can the confusion/delirium be further specified as: 1. Acute postoperative confusional state 2. Acute postoperative delirium 3. Other________________ 4. Confusion /delirium cannot be further specified

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Defining Altered Mental Status

? Neurocognitive Disorder (Dementia):

? DSM-V criteria

? Major impairment in learning and memory with associated impairment in task completion, reasoning, spatial ability, and language (i.e. independent living)

? Cognitive deficits interfere with work, social, and relationships

? Significant decline from previous level of functioning ? Insidious onset with progressive decline

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Clinical Case

80 year old patient documented to have dementia with delirium. Patient was agitated and pulling out Foley catheter. Patient's Risperdal dose was adjusted, and patient improved back to baseline. After study, can the dementia be further specified as:

1. Dementia with behavioral disturbance 2. Dementia with delirium only 3. Other___________ 4. Cannot provide further information

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Defining Altered Mental Status

? Encephalopathy

? Encompasses delirium and acute confusional state as psychological manifestations of brain dysfunction

? Global cerebral dysfunction ? Under recognized and undertreated!! ? Most reversible and treatable with prompt

recognition

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What, Confused?

Acute Encephalopathy:

? National Institute Neurologic Disease and Stroke: "Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure" ? UpToDate: "Acute toxic-metabolic encephalopathy which encompasses delirium and the acute confusional state, is an acute condition of global cerebral dysfunction in the absence of primary structural brain disease." ? The American Psychiatric Association DSM-V Manual doesn't recognize encephalopathy apart from delirium

Acute Delirium:

? Johns Hopkins Medicine: "Delirium is an acute disorder of attention and global cognition (memory and perception)" ? US National Library of Medicine (Medline): "Delirium is sudden severe confusion due to rapid changes in brain function that occur with physical or mental illness"

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Encephalopathy

? Cause: ? diffuse/focal cerebral dysfunction or dysfunction of brain stem

? Manifestation: ? cortical dysfunction (inattention, disordered thinking, behavior disturbances, delusions) and altered level of consciousness (hyper alert to coma)

? Symptoms: ? ranging from confusion/delirium to frank coma ? focal deficits (cognition) not uncommon as well.

? Usually systemic etiology including anoxic, metabolic, structural, and toxic

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Acute Mental Status Change

Acute Delirium Confusion Decrease LOC Hyperalert Psychosis Lethargy

Acute Mental Status Change

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Acute Brain Dysfunction Encephalopathy

No Brain Dysfunction

Metabolic

Structural Anoxic Toxic Psychological disorders

Types of Encephalopathy

? Metabolic encephalopathy (G93.41-MCC) ? Systemic cause including infection (septic), uremia, fluid and electrolyte disorders ? Marker for increased morbidity and mortality ? Correlates with changes in metabolism and function of nerve cells

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Metabolic Encephalopathy

Coding Clinic, Third Quarter ICD-10 2015 Page: 21 Assign code E11.649, Type 2 diabetes mellitus with hypoglycemia without coma, as the principal diagnosis. Assign also code G93.41, Metabolic encephalopathy, as an additional diagnosis.

Encephalopathy due to infection: Metabolic ........ Other? G93.41 Metabolic Encephalopathy includes septic encephalopathy G94 Encephalopathy in diseases classified elsewhere excludes

encephalopathy due to infections such as syphilis, influenza

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Clinical Case

Patient is documented to have confusion which is due to dehydration. The confusion improves with treatment by the time of discharge. EEG reveals slow wave pattern consistent with encephalopathy. After study, can the patient's confusion be further specified as: 1. Metabolic encephalopathy secondary to dehydration 2. Acute confusional state secondary to dehydration 3. Other______________ 4. Cannot provide any further information

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Clinical Case

The patient is admitted for acute renal failure, UTI, and hyperglycemia with associated altered mental status. Patient is documented to be more responsive with IV fluids. Per H&P the patient appears to have sepsis from UTI. After study can the patient's mental status be further specified as: 1. Metabolic encephalopathy 2. Acute confusional state due to underlying medical conditions 3. Acute delirium due to underlying medical conditions 4. Other _____________ 5. Altered mental status that cannot be further specified

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