Guest Post: Altered mental status remains a challenge in ICD-10-CM – part 2

By James Kennedy, MD, CCS, CDIP

Determine the underlying cause of the altered mental status

Remember that the various forms of altered mental states have underlying causes, which, if defined, diagnosed, and documented, accurately represent the patient’s condition for risk-adjustment purposes. Options include:

• Neurodegenerative disorders. To the extent that it’s possible to state what the underlying degenerative brain disease is, please do so. Options include Alzheimer’s disease, Lewy-body dementia, late effects of multiple strokes, normal pressure hydrocephalus, some cases of Parkinson’s disease, and a host of others. Note: The term “multi-infarct dementia” requires additional documentation that it is the late effect of multiple strokes. Consider the word “encephalopathy” as well (see the next item) when documenting these underlying causes.
• Encephalopathy. A challenging term that has many meanings, including, based on its etymology, any disease of the brain. Some physicians equate any mental status change with the term “encephalopathy,” not considering the underlying brain disease (e.g., a neurodegenerative disorder, cerebral edema, or encephalitis). I prefer the National Institute of Health’s (NIH) definition that an encephalopathy is “a term for any diffuse (emphasis added) disease of the brain that alters brain function or structure” that manifests as a defined altered mental status (e.g., delirium, dementia, psychosis) and requires specificity as to its underlying cause. The NIH’s definition can be found at www.tinyurl.com/NIHencephalopathy. As such, we must describe the diffuse brain disease causing the altered mental state, such as metabolic issues (e.g., hyponatremia, uremia, hypoglycemia), toxins (e.g., those that are directly toxic to the brain or that have been administered in a poisonous amount), hypertensive emergency, acute or chronic liver failure, and the like. Failure to document an underlying cause of an encephalopathy might subject a claim to denial, so always, if possible, specify what it is suspected to be.
• Coding Clinic, Second Quarter 2017, announced that if a physician documents that an encephalopathy is due to a lacunar stroke, the two are mutually exclusive and not inherent to each other, allowing G93.49 (other specified encephalopathy) to be coded along with the code for the stroke. Previous advice stipulated that the encephalopathy due to a post-ictal state is inherent to the seizure, thus not allowing the encephalopathy to be coded. It appears that Coding Clinic is allowing the coding of any specified encephalopathy; however, this is very controversial. Please discuss these with your coding managers, given that they need help knowing which conditions are integral to the term “encephalopathy” and which are not.
• Demyelinating diseases. These include multiple sclerosis, neuromyelitis optica, and others.
• Current effects of trauma or medications/chemicals. Designate whether the altered mental status is due to trauma or a medication/chemical and whether the diagnostic approach or treatment is in the active (“initial encounter”) or healing (“subsequent”) phase. Note if any medications or drugs were administered as prescribed or if taken in overdoses, qualifying them as poisonings. Document any drug-drug interactions causing the altered mental state; if alcohol or another recreational chemical is involved, this would be considered a poisoning. Identify any toxic encephalopathy that might be present. Coding Clinic, First Quarter 2017, stated that ciprofloxacin administered in proper doses can cause a toxic encephalopathy. The ICD-10-CM table for G92 (toxic encephalopathy) has an instructional note to code first the toxic effects of alcohol or other poison. The table also has an instructional note for T51 (toxic effect of alcohol) to use additional codes for “drunkenness” that are not included in the T51 codes. I believe this includes toxic encephalopathy from alcohol (or any other drug, for that matter) manifested by the intoxicated or drunken state.
• Late effects of trauma or drug overdoses. Document what brain diseases, such as post-concussive or anoxic encephalopathies, are the late effects or sequelae of various trauma or drug overdoses.

Editor’s note: Dr. Kennedy is the president of CDI MD, a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at jkennedy@cdimd.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. This article originally appeared in the Revenue Cycle Advisor.