Physicians Advisor’s Corner: Clearing the Confusion About Encephalopathy

By Andrew B. Maguir, MD, system director, Physician Advisor Program

The diagnosis of encephalopathy seems so nebulous, yet this diagnosis is paramount. Accurate documentation in the medical record helps capture the correct severity of illness and identify the reason for increased health care resource utilization.

My goal is to deliver counsel to providers and clear up some of the confusion surrounding encephalopathy. Encephalopathy is a term used for any diffuse disease of the brain that alters brain function or structure. The hallmark of encephalopathy is “altered mental status,” a clinical symptom not a diagnosis. Encephalopathies can be chronic, i.e., anoxic brain injury, Wernicke-Korsakoff syndrome, etc. or acute, i.e., metabolic or toxic.

Acute encephalopathy, most commonly encountered in the inpatient arena, is characterized by an acute global alteration in mental status due to systemic factors which, when treated, are reversible. The three types of acute encephalopathy include:

• Toxic encephalopathy: alteration in mental status due to toxins, drugs, or alcohol.
• Metabolic encephalopathy: alteration in mental status caused by metabolic abnormalities.
• Toxic and metabolic encephalopathy: a combination of toxins and metabolic derangements such as hepatic encephalopathy or encephalopathy due to acute renal failure.

Common neurological manifestations of encephalopathy include progressive memory loss and cognitive abnormalities, subtle personality changes, inability to concentrate, lethargy, progressive loss of consciousness, myoclonus, nystagmus, and loss of the ability to swallow or speak.

Acute encephalopathy may manifest as delirium which is a confused state of superimposed hyperactivity of the sympathetic limbs of the autonomic nervous system with consequent signs of tremors, tachycardia, mydriasis, or diaphoresis. The hallmark of delirium is waxing and waning attention. Delirium is a manifestation (symptom) of the altered mental status and Encephalopathy is the pathophysiology (medical diagnosis) causing the condition.

 From a clinical documentation standpoint, both toxic and metabolic encephalopathy serves as Major Comorbid Condition (MCC) for other unrelated Diagnosis Related Groups (DRGs). As of October 2018, “encephalopathy unspecified and other encephalopathy” serve as Comorbid Conditions (CCs). Hypertensive encephalopathy also serves as a CC. Hepatic encephalopathy codes as hepatic failure without coma K72.90 unless coma is specified.

Since there is not a consensus definition for encephalopathy in medical literature and the diagnosis is made clinically, it opens this diagnosis to Clinical Validation Denials. Health Insurance Payers can deny a diagnosis up to five years after a patient is released from the hospital, subsequently downgrading the final DRG and essentially take-back reimbursement from health systems. Encephalopathy complicating dementia is frequently denied by insurance audit review, so documentation of how the patient’s mental status is worse than baseline is paramount to support the diagnosis in the medical record. When delirium and encephalopathy are used interchangeably or alternatively in the same encounter, it raises the likelihood that an auditor will question the diagnosis of encephalopathy.

In addition to appealing these denials on the back end, our philosophy is to strengthen documentation on the front end to prevent denials.

Best practice documentation of encephalopathy:

• Link the diagnosis with the underlying etiology
• Support the diagnosis with clinical indicators including clinical symptoms and a Glasgow Coma Scale (GCS) score
• Make sure the diagnosis carries through the record from the time of diagnosis to the discharge summary with consistent documentation by all providers

To assist you in documenting encephalopathy accurately in the medical record we have created an Encephalopathy Macro or Dot Phrase in our electronic medical record. ENCEPHALOPATHY

[Acute/Chronic/Acute on Chronic] [Metabolic/Toxic/Metabolic-Toxic] Encephalopathy evidenced by [Clinical Indicators] due to [Etiology].

Providers, without a doubt you take excellent care of your patients, but you need to document well to get credit for having done so. You want the patient to look as sick and complex in the medical record as they appear in real life. Happy Documentation!!

References: 

American College of Physician Advisors, Encephalopathy for the Physician Advisor.

Back to the November 2019 issue of Premier Pulse.