What does it mean?

“Encephalo”-means Brain“Patho”-means Disease Encephalopathy is “caused by something else”

Implies a remote(outside of the CNS) etiology

SymptomsAlteration in mental statusLethargyPersonality changesLoss of memoryLoss of ability to speakHallucinationsLoss of ability to swallowSeizures or tremorsDelirium/Progressive loss of consciousness

Lab Tests That Help DiagnosisCBCLiver Function TestsAmmoniaBlood GlucoseSodium LevelBUN/CreatinineABG’sBlood CulturesToxicology Screens/Alcohol Levels

Other Tests That Help Diagnosis

CT Scan/MRIEEGUltrasoundCXRLumbar PunctureBlood pressure screening

ICD 9 Codes348.30 Encephalopathy, unspecified348.39 Other Encephalopathy348.31 Metabolic/Septic

Encephalopathy349.82 Toxic Encephalopathy291.2 Alcoholic Encephalopathy437.2 Hypertensive Encephalopathy572.2 Hepatic Encephalopathy

How The Codes Can Affect DRG348.30 Encephalopathy, unspecified =MCCMCC348.39 Other Encephalopathy =MCCMCC348.31 Metabolic/Septic Encephalopathy

=MCCMCC349.82 Toxic Encephalopathy =MCCMCC291.2 Alcoholic Encephalopathy =CC437.2 Hypertensive Encephalopathy =CC572.2 Hepatic Encephalopathy =MCCMCC

Metabolic/Septic Encephalopathy

Will usually see with Pneumonia or UTIUsually some underlying DementiaMay treat with anticonvulsants to reduce or halt seizuresMay change diet, Sodium Bicarb and/or add nutritional supplementsIn severe cases, may need dialysis or organ replacement

Toxic EncephalopathyUsually will see with poisonings of toxins/chemicals or medicines like lead, pesticides, or cleaning products but could also be from perfumes or air fresheners.

Treatment is mainly immediate removal from the exposure to the toxin

May also put on anticonvulsants or change diet/nutritional supplements

Alcoholic Encephalopathy

Also known as Wernicke-Korsakoff SyndromeFound in malnourished chronic alcoholics as

a result of thiamine deficiency (Vit B1)Will usually see with alcohol

withdrawal/delirium tremors(DT’s)Treatment consists of reversing the thiamine

deficiency by giving supplements of thiamine and possibly glucose

Hypertensive Encephalopathy

Started recognizing as a diagnosis in 1928It is a neurological dysfunction that is

induced by malignant hypertensionMost commonly seen in young to middle-aged

patients who suffer from hypertensionSymptoms usually start 12-48 hours after a

sudden sustained increase in blood pressure which is usually manifested by a severe headache

Hypertensive Encephalopathy

Look for cerebral edema on CT/MRITreatment is to lower BP with

antihypertensive drugs like Diazoxide, Hydralazine, Sodium Nitroprusside, and Nitroglycerine

May also be on Dilantin to control seizure activity

Hepatic Encephalopathy

Caused by an accumulation of toxins normally removed from the liver

Pt. has a history of alcoholism, cirrhosis, or hepatitis

Look for malnourished patientsTreatment is the administration of Lactulose

and/or LactitolSome antibiotics are given such as:

Neomycin, Metronidazole, and Rifaximin

Remember!Remember!

Encephalopathy is always due to an underlying cause.

The development of metabolic encephalopathy may be the first manifestation of a systemic disease-most importantly a diagnosis of Sepsis

Opportunity:  DRG - DI (Query for encephalopathy)

Case Summary:  Admitted  from NH with confusion, lethargy, decreased output.  Alzheimer's dementia.  Temp 99.5,  90% RA.  Multiple electrolyte derangements. (H&P) Worsening renal function consistent with rhabdo, dementia with acute delirium.  DCS:  …."significant improvement in mental status".  CDS query for type of dementia - response.   Query supported with change in mental status and several contributing factor:  dehydration, UTI, ARF, electrolyte abnormalities all superimposed on severe Alzheimer's dementia.

Discuss: Additional query clarification for DCS comment that patient's admission diagnosis was "dementia of acute delirium" - ? - not sure what that is...likely query 

Case Study #2 Opportunity:  DRG - Coding (Suggest re-sequence hypertensive encephalopathy as Pdx). 

Case Summary:   Pt. presents to ED 2/27 0700 with AMS, resp distress,  hypertensive urgency  (HTV cardio and renal disease), ESRD, and CHF secondary to right heart failure.  EMS record:  244/124, 223/116, 220/100 in the ER pt. received IV meds Hydralazine:  10 mg IVP, 20 mg IVP, Labetalol 10 mg IVPX2, Cardene 2.5 mg IVP X2,.  Consult note states ? malig HTN v CVA.  Also Nephro consult states HTN encephalopathy.  Dr. Adams "admit to Critical for management and monitoring of HTN".   Stroke code called. CT/MRI in ED (-), no repeat.  (PN  2/27) TIA/CVA; (Neuro consult 2/27 11:42am) -"mild ptosis R eye...unable to communicate....inarticulate speech...gag blunted....probable CHF diastolic with LV dysfunction"; (PN 2/28) CVA, ; (Neuro consult 2/27 11:42am) - "mild ptosis R eye...unable to communicate....inarticulate speech...gag blunted....probable CHF diastolic with LV dysfunction, possible component of HTV encephalopathy"; (PN Neuro 2/27 8 pm) "language improving....probable dx hypertensive urgency; (PN 2/28 Neuro) All sign&symptoms gone; (PN 2/28 renal) "HWD/Hypertensive urgency"; (3/3 Renal) ? hypertensive encephalopathy . 2 CDS queries:   acuity of CHF (no response, no impact for this case), TIA/CVA (responded); (PN 3/3) TIA(coded as TIA).

Discussion:  Coding guidelines for possible/probable dx.  Definition of terms - CVA: Physician education re: CVA definitions and options:  PN 2/28 states MRA/MRI CT negative but pt. documented as having Neuro deficits >1 h after presentation to hospital.   Definition of terms:  malignant hypertension:  Even at these high levels, a hypertensive emergency (i.e., accelerated or malignant HTN) is only diagnosed if this is an acute change and if an optic exam is noted.  Both have accelerated HTN and malignant HTN have end organ damage (as in this case) - the only difference is a bulging optic disk. NN doc:  to  as documentation source to identify status of neuro deficits?

Query Example 1

Questions… Discussions??

Cathy Lips, CCSCoding EducatorSpartanburg Regional