What should you call that encephalopathy?

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Confused about confusion? I was too until I did some digging and realized it’s actually quite simple.

First, what does encephalopathy mean? In Latin:

Encephalo = Brain

Pathy = disorder

Literally, it means brain disorder.

“Altered mental status,” is a SYMPTOM (NOT a diagnosis) DUE TO the underlying brain disorder. Many document “altered mental status” and then under it list other problems like sepsis or hypercalcemia. But that’s not capturing the true complexity of the underlying brain disorder - which is encephalopathy.

As with many things, encephalopathy can be acute or chronic (or acute on chronic). ACUTE encephalopathies are due to systemic underlying causes and improve steadily as they are treated (this will be important later).

MOST of these acute underlying causes fall into two buckets:

1. Metabolic

2. Toxic

Metabolic is due to INTERNAL causes such as sepsis, dehydration, hypernatremia, hypoglycemia, hypercalcemia, hypoxia, organ failure, acidosis, etc.

Toxic is due to EXTERNAL causes such as alcohol, drugs, medications, chemicals, toxins, etc.

So “Acute Metabolic Encephalopathy” or “Acute Toxic Encephalopathy” are going to be most of the encephalopathies you see in the hospital and should be the documentation tools you take away from this. You can also have both at the same time.

For toxic encephalopathy due to a prescribed medication, mention in your documentation whether the medication was taken appropriately or inappropriately.

Alcohol is on the list of toxic encephalopathy, so….

Should I call alcohol intoxication, “alcohol encephalopathy?”

NO! “Alcohol encephalopathy” is the CHRONIC condition that results from the permanent damage to the nervous system due to alcohol. So, use “acute toxic encephalopathy” instead.

What about delirium tremens? Well, in that case the toxin is actually ABSENT. So…it’s not toxic encephalopathy. It’s simply alcohol withdrawal with delirium (which is still a CC, as mentioned below).

Is delirium an encephalopathy?

Remember, acute encephalopathies improve steadily as they are treated. What is one of the defining features of delirium? It waxes and wanes. Up, down, up down. We’ve all seen it. So, delirium, and sundowning, are not encephalopathies. Compare the graphs below:

However, the two are not mutually exclusive. You can have a UTI causing metabolic encephalopathy but then the patient experiences hospital acquired delirium as their underlying metabolic encephalopathy improves. The same goes for toxins. You can have a toxic encephalopathy that causes some delirium. So, the graph might look something like this:

When a patient with dementia comes in with a sudden change in mental status, it can be difficult deciphering encephalopathy versus delirium. Sometimes, you just don’t know until you perform a work-up and observe the course. If nothing is found, perhaps it’s simply delirium or “sundowning.” However, remember a work-up for encephalopathy is incomplete without a review of the medication list - which may suggest a cause of a toxic encephalopathy.

The dementia example above can cause some to think “oh, if an encephalopathy is not resolved by the time of discharge, then it must mean it’s a chronic condition.” That is not universally true. Think of a patient who has progressed to ESRD and presents with uremic encephalopathy. Hemodialysis is initiated in the hospital, but the patient is discharged before the uremic encephalopathy is completely resolved. That is clearly an acute encephalopathy. (I mention this because insurances have been known to use this flawed argument)

Can I document “encephalopathy” and let the coder pick up the underlying cause based on my description?

No, you must specifically name it. Coders cannot assume anything.

Show me the MCC / CC Chart!

As I am always having new subscribers, I reference this article in almost every newsletter issue. If you don’t know what MCC’s and CC’s are, read my previous issue: What are CC’s and MCC’s? And why do they matter? (beehiiv.com)

That is by no means an exhaustive list. Note that if you just say “encephalopathy” without being specific, it’s only a CC. Also note that alcoholic encephalopathy, which I mentioned earlier, is neither an MCC nor CC.

You haven’t mentioned Hepatic encephalopathy…

This is a weird one. It’s considered just a part of chronic liver failure and NOT under any of the categories above, including metabolic encephalopathy, unless they have overt coma (in which case it’s an MCC: chronic hepatic failure with coma). However, if a patient has ANOTHER type of encephalopathy on top of their hepatic encephalopathy, make sure to document that because otherwise, hepatic encephalopathy gets you little “credit.”

So, to summarize:

1. Avoid using “Altered Mental Status” as a problem / diagnosis.

2. Most acute encephalopathies in the hospital are going to be either:

   • Metabolic due to INTERNAL causes such as sepsis, dehydration, hypernatremia, hypoglycemia, hypercalcemia, hypoxia, organ failure, acidosis, etc.

   • Toxic due to EXTERNAL causes such as alcohol, drugs, medications, chemicals, toxins, etc.

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That’s all for now. I hope that was helpful.

Cheers,

Robert

P.S. Let me know what you think of the newsletter name change to “Doctoring with Documentation” rather than “Dr. Oubre’s Digest.” I haven’t quite made it official yet.

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