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Documentation Tip of the Week: Encephalopathy

Posted on Tue, Mar 03, 2015
Documentation Tip of the Week: Encephalopathy

Encephalopathy is defined as a diffuse disease of the brain that may alter brain function or structure. This diagnosis may be caused by infection, metabolic disorders, mitochondrial disorders, brain tumor, brain pressure, chronic progressive trauma, poor nutrition, lack of oxygen to brain, or prolonged exposure to toxic elements.

Types of Encephalopathy include:

  • Septic Encephalopathy
  • Metabolic Encephalopathy
  • Toxic Encephalopathy
  • Hypertensive Encephalopathy
  • Hepatic Encephalopathy
  • Anoxic Encephalopathy
  • Hypoglycemic Encephalopathy
  • Traumatic Encephalopathy
Encephalopathy is an MCC and therefore impacts severity of illness and risk of mortality. When caring for a patient with altered mentation, consider if the patients’ altered mental status is due to one of the above conditions/diagnosis.

Encephalopathy is a highly audited diagnosis due to over use and over coding. The diagnosis should warrant treatment of the underlying condition. Beware if the patient has dementia or AMS due to medication administration; not all confusion is Encephalopathy. This documentation will support your patient being as sick on paper as they are in the bed.

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

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