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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