Q&A: Encephalopathy “off baseline”

Q: Our neurologist often documents encephalopathy for many of our patients. If an elderly patient came in with altered mental status (AMS), delirium, and has baseline dementia, can we code encephalopathy? What if the physician documents “encephalopathy, off baseline?” Ideally, the physician should specify the type of encephalopathy, but we need to provide more education for this at our facility. In the meantime, is “off baseline” sufficient?

A: I know it probably seems like there are a lot of rules and regulations that must be followed, and I am sure your head is spinning trying to keep them all straight. Ultimately, a physician can use any clinical indicators/evidence to diagnosis a patient he/she feels appropriate.

As CDI specialists, we want to make sure the diagnosis is documented in the medical record to the highest level of specificity, appropriate for the patient, within the encounter we are reviewing. Our job is to make sure the documentation is complete, accurate, and appropriately reflects the patient’s clinical conditions.

Once the physician documents the diagnosis, we may need to query for the clinical indicators/evidence they used to diagnosis a patient, but always remember that the physician determines which indicators they choose to use. And, as you mentioned, a lot of our job is educating the providers regarding the information needed in the medical record to appropriately code a chart, including the type of encephalopathy, the patients “normal” baseline, and whether or not the patient returned to their baseline.

I would also suggest you have a conversation with the coding staff at your facility. We need to be aware of any other issues that may be present, such as whether or not your facility has any internal policies in place that you may not be aware of when it comes to the documentation and coding of certain diagnoses.

Take a look at the Official Guidelines for Coding and Reporting, Section 1.A.19:

“The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists.  The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview. Additional resources include:

• ACDIS Radio focused on encephalopathy, click here.
• An article by Brodie about encephalopathy documentation requirements, click here.
• A Q&A about reporting altered mental status and encephalopathy, click here.
• A presentation from the 2018 ACDIS Conference about encephalopathy, click here.
• An on-demand webinar focused on altered mental status documentation, click here.