Encephalopathy: A Challenge

1. Encephalopathy: A Challenge

2. What does it mean? • “Encephalo”-means Brain • “Patho”-means Disease • Encephalopathy is “caused by something else” • Implies a remote(outside of the CNS) etiology

3. Symptoms • Alteration in mental status • Lethargy • Personality changes • Loss of memory • Loss of ability to speak • Hallucinations • Loss of ability to swallow • Seizures or tremors • Delirium/Progressive loss of consciousness

4. Lab Tests That Help Diagnosis • CBC • Liver Function Tests • Ammonia • Blood Glucose • Sodium Level • BUN/Creatinine • ABG’s • Blood Cultures • Toxicology Screens/Alcohol Levels

5. Other Tests That Help Diagnosis • CT Scan/MRI • EEG • Ultrasound • CXR • Lumbar Puncture • Blood pressure screening

6. ICD 9 Codes • 348.30 Encephalopathy, unspecified • 348.39 Other Encephalopathy • 348.31 Metabolic/Septic Encephalopathy • 349.82 Toxic Encephalopathy • 291.2 Alcoholic Encephalopathy • 437.2 Hypertensive Encephalopathy • 572.2 Hepatic Encephalopathy

7. How The Codes Can Affect DRG • 348.30 Encephalopathy, unspecified =MCC • 348.39 Other Encephalopathy =MCC • 348.31 Metabolic/Septic Encephalopathy =MCC • 349.82 Toxic Encephalopathy =MCC • 291.2 Alcoholic Encephalopathy =CC • 437.2 Hypertensive Encephalopathy =CC • 572.2 Hepatic Encephalopathy =MCC

8. Metabolic/SepticEncephalopathy Will usually see with Pneumonia or UTI Usually some underlying Dementia May treat with anticonvulsants to reduce or halt seizures May change diet, Sodium Bicarb and/or add nutritional supplements In severe cases, may need dialysis or organ replacement

9. Toxic Encephalopathy Usually 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

10. Alcoholic Encephalopathy • Also known as Wernicke-Korsakoff Syndrome • Found 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

11. Hypertensive Encephalopathy • Started recognizing as a diagnosis in 1928 • It is a neurological dysfunction that is induced by malignant hypertension • Most commonly seen in young to middle-aged patients who suffer from hypertension • Symptoms usually start 12-48 hours after a sudden sustained increase in blood pressure which is usually manifested by a severe headache

12. Hypertensive Encephalopathy • Look for cerebral edema on CT/MRI • Treatment is to lower BP with antihypertensive drugs like Diazoxide, Hydralazine, Sodium Nitroprusside, and Nitroglycerine • May also be on Dilantin to control seizure activity

13. 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 patients • Treatment is the administration of Lactulose and/or Lactitol • Some antibiotics are given such as: Neomycin, Metronidazole, and Rifaximin

14. 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

15. Case Study #1

16. 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?

17. Query Example 1

18. Query Example 2

19. Questions… Discussions?? Cathy Lips, CCS Coding Educator Spartanburg Regional