Encephalopathy: A Challenge

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Encephalopathy A Challenge
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What does it mean?

• Encephalo-means Brain
• Patho-means Disease
• Encephalopathy is caused by something else
• Implies a remote(outside of the CNS) etiology

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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

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Lab Tests That Help Diagnosis

• CBC
• Liver Function Tests
• Ammonia
• Blood Glucose
• Sodium Level
• BUN/Creatinine
• ABGs
• Blood Cultures
• Toxicology Screens/Alcohol Levels

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Other Tests That Help Diagnosis

• CT Scan/MRI
• EEG
• Ultrasound
• CXR
• Lumbar Puncture
• Blood pressure screening

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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

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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

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Metabolic/Septic Encephalopathy

• 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

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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

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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(DTs)
• Treatment consists of reversing the thiamine
  deficiency by giving supplements of thiamine and
  possibly glucose

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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

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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

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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

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• 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

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Case Study 1

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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 1142am) -"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 1142am) - "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 signsymptoms 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 gt1 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?

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Query Example 1
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Query Example 2
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Questions Discussions??

• Cathy Lips, CCS
• Coding Educator
• Spartanburg Regional