Q&A: Encephalopathy as integral to seizures/CVA

Q: The physician documented “encephalopathy” in the record of a patient who was admitted with a cerebral vascular accident (CVA) and/or possible seizures. The patient was confused but has returned to baseline. Are these conditions considered interrelated or can we code for the encephalopathy to capture an MCC?

A: As a comorbid secondary diagnosis, the presence of an acute encephalopathy can be either a CC or MCC depending on the type. If the documentation in the medical record is unclear, query the provider. Unfortunately, the particular situation you describe may lead the coders to assign unspecified encephalopathy which could be an MCC if the physician further specified “hypertensive encephalopathy.”

The AHA’s Coding Clinic ICD-9-CM, Fourth Quarter 2013 had an entry related to this topic (regarding discharge summary documentation) which read:

“[O]n admission the patient had mental status changes, which subsequently resolved. Consequently, we determined the patient had encephalopathy secondary to postictal state. Should encephalopathy be reported as an additional diagnosis with seizure when it is due to a postictal state? Would encephalopathy be considered inherent to the seizure or can it be reported separately?”

“ANSWER: Encephalopathy due to postictal state is not coded separately since it is integral to the condition...The postictal state is a transient deficit, occurring between the end of an epileptic seizure and the patient's return to baseline. This period of decreased functioning in the postictal period usually last less than 48 hours.”

This Coding Clinic only gives advice regarding the diagnosis of encephalopathy being integral to seizures, not to a CVA. Coding Clinic for ICD-10-CM/PCS, First Quarter 2014, says to report any neurological deficits caused by a CVA, with or without treatment, even if they are resolved at the time of discharge from the hospital.

One final word about this, a reminder, that in order for a condition to warrant code assignment as a secondary diagnosis it must require clinical evaluation, therapeutic treatment, diagnostic procedures, and increase nursing care or length of stay for a patient. 

Hope this helps!

Editor’s Note: Sharme Brodie RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, 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.