Using the Right ICD-10 Codes to Document Encephaloopathy

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2. 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. www.outsourcestrategies.com

3. Common Types of Encephalopathy Toxic encephalopathy Metabolic encephalopathy Anoxic encephalopathy Hepatic encephalopathy Hypertensive encephalopathy Acute encephalopathy Chronic traumatic encephalopathy (CTE) www.outsourcestrategies.com

4. 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 www.outsourcestrategies.com

5. ICD-10 Codes to Document Encephalopathy G92 - Toxic 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 www.outsourcestrategies.com

6. G93.1- Anoxic Encephalopathy 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 www.outsourcestrategies.com

7. G93.40 - Encephalopathy, Unspecified G93.41 - Metabolic Encephalopathy 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 www.outsourcestrategies.com

8. I67.4 - Hypertensive Encephalopathy 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 www.outsourcestrategies.com

9. K72.90 - Hepatic Failure, Unspecified without Coma 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 www.outsourcestrategies.com

10. 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. www.outsourcestrategies.com

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