Using the Right ICD-10 Codes to Document Encephaloopathy

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• Encephalopathy refers to any brain disease that
  alters brain function or structure. Medical
  coding companies often come across the diagnosis
  of this disorder, for which they need to be
  up-to-date with the latest medical codes related
  to this.

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Common Types of Encephalopathy

• Toxic encephalopathy
• Metabolic encephalopathy
• Anoxic encephalopathy
• Hepatic encephalopathy
• Hypertensive encephalopathy
• Acute encephalopathy
• Chronic traumatic encephalopathy (CTE)

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The diagnosis is based on

• History and physical exam
• Lab findings CBC, liver function tests, ammonia
  and blood glucose levels, lactate levels,
  kidney function tests, blood cultures, virology
  testing, and or ABGs
• Neuroimaging studies
• EEG findings

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ICD-10 Codes to Document Encephalopathy

• Usually irreversible, this disorder is caused by
  the interaction of a chemical compound with
  the brain
• Substances that cause the condition include
  drugs, radiation, paints, industrial
  chemicals, and certain metals solvents,
  medications or drug ingestions, radiation,
  paints, industrial chemicals, and certain metals

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Also referred to as hypoxic encephalopathy, it is
caused by brain damage due to lack of oxygen.
Anoxic brain damage can occur

• If blood flow to the brain is blocked or slowed
  due to a blood clot
• Due to stroke, heart attack, lung disease,
  prolonged exposure to certain poisons or
  toxins, or any incident that compromises breathing

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• Acute encephalopathy is caused by either a
  direct injury to the brain or an illness
• Correction of these abnormalities can reverse
  the condition
• It may be further identified as toxic,
  metabolic, or toxic-metabolic

• Caused by underlying conditions such as
  infections, toxins, or organ failure
• Usually resolves when the underlying chemical
  imbalance is restored or offending
  infection/toxin is eliminated

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• The condition is caused by extreme high blood
  pressure levels
• Usually leads by severe headache and followed by
  convulsions, coma or a variety of transitory
  cerebral phenomena
• Treatment aims at decreasing blood pressure and
  most often the effects are reversible

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Observed in patients with cirrhosis or liver
disease, this syndrome can harm the liver and the
organ cannot remove toxin from the blood

• It is characterized by personality changes,
  intellectual impairment, and a depressed
  level of consciousness. Coma may or may not be
  present
• Appropriate treatment and compliance with
  protocols could reverse the condition
• Around 30 of patients with end-stage liver
  disease experience significant encephalopathy

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Documentation Tips

• The documentation should include terms like
  toxic encephalopathy or metabolic
  encephalopathy and describe what the toxin,
  poison, or metabolic issue is
• Details such as types of condition, description
  of symptoms, and underlying cause should be
  documented
• Other signs and symptoms not associated
  routinely with a disease process should also
  be coded when present
• If a patient has both delirium and
  encephalopathy at the same time, both due to
  the same cause, both can be coded if each
  required their own diagnostic workup or
  interventions.

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