Q&A: Denials for encephalopathy

Q: We are receiving denials on the grounds that encephalopathy must be resolved prior to discharge in order to be present. How would you suggest we fight these denials?

A: It’s a common misconception that encephalopathy has only one definition. Encephalopathy can be either metabolic/transient or chronic/progressive/degenerative. There’s no one definition which describes all types of encephalopathy. Let’s look at some examples below:

• Metabolic
• Septic
• Toxic
• Alcoholic
• Hypoxic
• Infectious
• Ischemic
• Uremic
• Structural
• Wernicke’s
• Hypertensive

And this isn’t even a comprehensive list.

The implication contained within your description of the denials your facility is receiving seems to be limited to the types of encephalopathy which are treatable (at least I hope it is). Even within this subset, however, you may not always see a 100% resolution of symptoms if the patient discharges with the metabolic disturbance still present.

For example, think of the diagnosis of uremic encephalopathy where the patient is discharged to hospice still in renal failure. In such a situation, the uremic encephalopathy would still be present at discharge. We can, however, make a rough approximation of two distinct categories—one set which may be reversible and another set which likely isn’t.

Treatable encephalopathy types include:

• Metabolic
• Septic
• Toxic
• Hypoxic
• Infectious
• Hypertensive
• Uremic

Encephalopathy categories that are unlikely to be fully corrected include:

• Alcoholic
• Ischemic
• Structural
• Wernicke’s

Remember, though, that this is just a rough approximation and there is likely to be some variation in a patient’s response to treatment even within these two broad categories.

That said, the insurance company may be inferring that a patient’s apparently stable dementia is more representative of a chronic neurological process such as Alzheimer’s in a patient who has metabolic encephalopathy reported on the claim. In such a circumstance, I can understand the auditor’s point of view.

If there was no difference between the acute illness phase mental status function and after the metabolic issue was supposedly corrected in a patient with pre-existing dementia or degenerative neurological process, the case for an acute metabolic encephalopathy is less probable. The argument for one of the chronic progressive degenerative types of encephalopathy may still be on the table here though.

This highlights one very important thing with the new era of CDI: attempting to ascertain the patient’s pre-existing baseline status. Baseline status is of paramount importance for the clinical validation of several diagnoses, including malnutrition, acute kidney injury, encephalopathy, dementia with behavior disturbance. Establishing a baseline status is even helpful for less obvious concerns such as differentiating an elevated troponin from a Type 2 in myocardial infarction or differentiating an acute congestive heart failure (CHF) from end-stage CHF in a patient who presents with wet lungs.

The only thing I can say for certain is that the blanket statement “encephalopathy must be resolved prior to discharge to be considered valid” is categorically false. If this is the basis of the denials you’re receiving, I absolutely recommend bringing your physician and/or neurologist in on the process of appeal writing and dealing with that particular insurance company.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.