Watch the recorded webinar below…


0:05 Everyone, and welcome to Roundtable 151.
0:08 Thank you for taking the time out of your day to join us.
0:10 My name is Scott …, I’m the Vice President of Coding Education and Continuous Improvement for …, H I M Division.
0:17 Bear with me today is Doctor Keene Okolloh and she’ll be presenting CDI strategy for Altered Mental Status.
0:26 A challenging topic for sure, doctor Okolloh slide, Kirsten, There we go.
0:35 Doctor Polo is serves as our CDI physician advisor and has a unique combination of experience in the academic and clinical setting complemented by great business acumen.
0:46 I’m looking forward to your presentation as much as you all.
0:49 So let’s get through the rest of this quickly.
0:52 Some housekeeping, there’s no color numbers. The format is streaming only.
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1:49 We have our roundtables scheduled for quarter four up there now.
1:53 Quick survey at the end of the webinar, please take a minute to answer the very straightforward questions. It helps us gage if we are hitting the mark.
2:00 Also helps us to understand if there’s anything that we could help your organization work.
2:04 So with no further ado, I’m going to move in and move and move on and turn the presentation over to doctor McCulloch.
2:14 Well, good morning, everyone. Thank you so much for taking the time to attend today. I am today. We will be talking about why altered mental status is very important in clinical documentation improvement.
2:28 And for the course of this presentation, we would first of all, start off with the definitions of altered mental status, the theologies that we should be thinking about.
2:39 And also, Why is it important and what is one of the most frequently died? What what is one of the most frequently denied etiology of altered mental status? I would also go over some clinical documentation tips, and, of course, if, and, of course, I would go through the case examples that I prepared for today. And if you have any questions, hopefully, we would be able to get through the questions today.
3:11 OK, so, first of all, what do we even mean by mental status?
3:17 Well, when we talk about someone’s mental status, we’re talking about how both their brain and their buddy work together.
3:26 But when we say that a person’s altered, a person’s mental status is all Ted, then we’re talking about how, our lead, the eye, or how aware that they are to their surroundings, or what’s going on around them.
3:42 It’s very important to be able to detect the early signs of altered mental status.
3:48 Because, if we’re able to do that, then we’ll be able to check for the underlying theologies or the underlying causes and be able to treat appropriately to prevent further.
4:02 To prevent, to prevent the risk of mortality or morbidity. It’s also important to note that the differential diagnosis for altered mental status is very vast. but when we see a patient that comes in with altered mental status, there are five categories that should come to mind.
4:20 one of them includes infections, possible encephalopathy, Cs, possible drug related causes, cardio pulmonary causes, and maybe some neurology causes as well.
4:33 And with a differential diagnosis being very vast. Altered mental status could be caused by something as small as a urinary tract infection, or something as big as a stroke.
4:52 Could we go to the next slide?
4:57 And so what I, what I’m doing in the next two slides is I’m just trying to break down the possible etiologies of altered mental status.
5:07 Please keep in mind that is still much bigger than these next two slides. When we are thinking about possible causes of infectious, when we’re thinking about possible infectious causes of altered mental status on patients with pneumonia could be altered. Patients that are septic could be altered. UTI patients could also be altered as well.
5:31 When it comes to metabolic or toxic situations the patient could have toxic or a metabolic encephalopathy, they could also have hepatic encephalopathy. They could have alcohol ingestion, causing them to have encephalopathy, which is causing them to the Alt Ed. And, you know, even your hypoglycemic patients could also be altered as well.
5:56 Next slide, please.
5:59 Neurologic causes could include patients that are suffering from maybe a subdural hematoma, which is literally a brain bleed.
6:11 Uh, thank you which is literally bleeding in the brain in the sterile veins of the of the brain.
6:20 They could also be altered from a sub … hemorrhage as wall. They could also be altered with when they have a myocardial infarction, which is a cardiac arrest, they could be altered from a pulmonary embolism. Maybe you have a truck driver that came in from a really long drive. And he started presenting with shortness of breath, and he’s also having some chest pain, and he’s also all said it could be a pulmonary embolism that is causing this entire presentation.
6:51 Patients that are maybe taking excessive numbers of medications also known as polypharmacy could be altered. They could also be altered from alcohol or drug withdrawals as well.
7:10 So why is altered mental status very important in clinical documentation.
7:19 So, when it comes to altered mental status, we have about six, and this is just an approximation, about 50% of hospitalized order adult patients present each year with altered mental status. And it costs about 164 billion in annual health care expenditures to take care of patients with, for example, delirium.
7:41 And besides the cause store, you know, besides the the admissions, we also have the task of CDI specialist and Cortez trying to capture a complete picture for this patient, because, at the end of the day, when this chart’s get billed.
8:00 No, the auditors or whoever that is reviewing the chart after.
8:04 They don’t have the patience in front of them, so all that they have to go off off is what they see on paper.
8:12 And this is why documentation is very, very important when it comes to symptom code. I’m going to say symptom code because that’s exactly what it is altered mental status is, is symptom code.
8:25 And because it is a symptom code, it doesn’t really carry much value in the risk models. It doesn’t really it’s not a DRG driver. So it’s not really going to affect the SRY or the IOM which is severity of illness and risk of mortality.
8:42 That being said, CDI specialists are called as C, The documentation of altered mental status, unspecified, aina patient chart.
8:53 It is their responsibility to query the provider for more specificity, because, when they went the providers document much better, then this would carry a much higher weights in the coding system.
9:09 And it also helps to show how sick that the patient is, especially when all the clinical indicators at present, you know, it doesn’t make sense to take care of a patient for this length of time, and we can’t even show it in the documentation. And that also plays a part in how the hospitals or the clinics are reimbursed for all their work.
9:33 And so I just put a little example at the bottom, showing how no, this can this could have been better. For example, we had, oh, I saw a chart where a doctor had documented that the patient had a UTI hypotension, Acute kidney injury, altered mental status and metabolic encephalopathy.
9:53 But he didn’t, or he or she did not connect.
9:56 No, they didn’t pick the puzzle together and what would have made for a much better documentation is if the altered mental status was maybe linked to the metabolic encephalopathy, depending on what the patient was presented with, or also the fact that the patient has a urinary tract infection, it’s all Ted and also has metabolic encephalopathy.
10:18 An API, A diagnosis of severe sepsis, could have also been made with the fact that the patient has hypotension has a UTI, you know, an infection is present, and also has acute kidney injury, this could mean that there is severe sepsis, also with the fact that the patient does have an organ dysfunction. But, at the end of the day, it’s all dependent on the sepsis criteria of the facility. Some facilities use sepsis to some facilities use sepsis three.
10:51 But, you know, in summary, what I’m trying to say is, when you have a patient that, it’s all Ted, and you can connect the dots, or you can query the provider, please go ahead and do so for it. And I’m talking to CDI specialist and quarters.
11:07 But I’m also trying to show, you know, the the, the importance of clinical documentation with altered mental status.
11:16 I also came across this really nice mnemonic on the internet when I was doing some research. And it’s AI or AI or you tips.
11:26 And it’s just a mnemonic showing how you could maybe to help to trigger your memory. When you’re thinking of possible causes of altered mental status, you see that alcohol could cause altered mental status, encephalopathy infection and, you know, the list goes on. Really.
11:49 Next slide, please.
11:52 And this slide really is just saying almost everything I just said in the last slide, basically.
12:00 Here we have a patient that came in with acute renal failure.
12:06 And, um, acute renal failure was the primary dark diagnosis, or it was the principal diagnosis.
12:13 And the secondary diagnosis on the left was altered Mental Status Coronary artery disease, type two type of epidemic morbid obesity. And we see the relative weights to be zero point six two eight five.
12:28 If we look down, we see the length of stay is 2.8, reimbursement, 2979 dollars.
12:37 Now, if there was a much better documentation, or if the altered mental status was linked to encephalopathy, or maybe delirium, maybe the patient, will, you know, maybe the provider cell that the patient just had delirium, then that shows a watch or you can see a much higher relates, a weight on the right hand side.
13:01 You also see that, even though the severity of illness is not really changing, the length of stay is changing. So, that is explaining why this patient has to be in the in the hospital for longer.
13:16 And it is justifying the reimbursement value which you see at the bottom as well.
13:26 So that leads me to the next portion of the presentation, which is which which is one of the most frequently denied altered mental status diagnosis, which is encephalopathy.
13:44 So what is encephalopathy?
13:46 Well, according to the National Institute of Neurologic Disorders and Stroke of the NIH, it is defined as any diffuse disease of the brain that all taz brain function or brain structure.
14:02 Encephalopathy could be divided into two classifications, it could be divided into acute, functional, encephalopathy, or chronic structural encephalopathy.
14:16 It’s very important to note that encephalopathy is often the most common cause, or it’s one of the most common causes of a patient coming in with altered mental status. And because it’s such a serious medical condition, it often requires inpatient care.
14:33 And whenever that is the cause of the patient getting admitted into the hospital, then pair coding guidelines, it will become the principal diagnosis.
14:47 That that’s not to say that it cannot be a secondary diagnosis. Sometimes you can have patients where encephalopathy is a secondary diagnosis. And you know, we’ll go over that in subsequent slides.
15:08 Next slide, please.
15:14 OK.
15:15 so how would we tell apart acute encephalopathy from chronic encephalopathy?
15:22 While acute encephalopathy is when the brain function is altered? And usually there is an underlying cause there’s something that is causing the brain function to be altered.
15:36 And because of this, if you are able to correct the underlying cause, it is irreversible type of encephalopathy.
15:45 When it comes to acute encephalopathy, there are no structural changes. It’s just the function of the brain that is altered.
15:51 And on the right hand side, these images just show a patient that is, this is a, this is actually 5 to 9 year old female, that is coming in with corvid.
16:03 The patient also presented with respiratory distress and altered consciousness.
16:09 And if you if you look on the right, the brain looks perfect, there’s literally nothing that is going on in this brain, it’s just that the patient is coming in altered because there is a functional change in the brain.
16:27 Next slide.
16:30 So, there are different causes of acute encephalopathy besides ….
16:36 Metabolic there could. There could also be metabolic causes of encephalopathy and this could include infection acidosis, dehydration, a lot of times you see encephalopathy, or metabolic encephalopathy being caused by electrolyte imbalances as well.
16:55 Toxic encephalopathy is a type of encephalopathy that is caused by the effects of drugs or toxins.
17:02 And then when we, when we hear toxic and toxic metabolic encephalopathy, this is as a result of the combination of both toxic and metabolic factors.
17:15 Septic encephalopathy is usually due to severe sepsis.
17:20 Patrick encephalopathy is often seen in patients with long standing alcohol use and usually when they, when they go into severe end stage liver disease, this is when they could stop presenting with hepatic encephalopathy.
17:39 And in that case, when you see this type of patient, it’s always a good idea to check the ammonia levels because most times it’s elevated.
17:49 Are 10 SIV encephalopathy is due to severe hypertension.
17:55 The patients could present with headaches, confusion.
18:00 A lot of times, they could also present twists.
18:03 Sometimes they could have convulsions or maybe not.
18:07 It really just depends on the type of patient that is, you know, that is present in at that point hypoxic or anoxic encephalopathy. It’s important to note that this is different from hypoxic ischemic encephalopathy.
18:24 because hypoxic or anoxic, encephalopathy is seen in patients with permanent chronic damage, due to prolonged hypoxic, hypoxia, hypoxia. So lack of oxygen to the brain literally, and hypoxic ischemic encephalopathy is a peak code. So that’s a pediatric patient.
18:47 and it’s often seen in premature infants when they do not have oxygen flowing into their brain at delivery.
18:57 And this is different from neonatal encephalopathy because even though it’s a P code as well and even though it’s seen in babies, the only difference here is that neonatal encephalopathy, the babies are full term. They’re not pre-term.
19:13 Oh, I’m sorry, they’re not premature.
19:17 Next slide, please.
19:21 And when it comes to chronic encephalopathy, here, what’s happening is that the patients have structural changes to the brain.
19:30 And this is due to no consistent injury to the brain causing permanent brain damage.
19:39 Chronic encephalopathy is not reversible.
19:42 There, of course, they’re etiologies that would lead a patient to having chronic encephalopathy. But it’s not as it’s not reversible compared to acute encephalopathy.
19:54 It could be seen in patients with prolonged alcohol use, where they have whether developed something called Werne Kiene … syndrome.
20:05 They could also chronic encephalopathy could also be seen in patients with chronic traumatic encephalopathy.
20:13 That is, um, lot of times it’s seen as football players where there’s consistent trauma to the brain and Army could also be seen in patients with hereditary metabolic disorders as well.
20:31 So, what are the client, the clinical documentation tips that I have today?
20:36 Well.
20:40 My clinical documentation tips really stem from specificity and it has a lot to do with encephalopathy just because this is one of the major issues, when it comes to altered mental status, Um, diagnoses are when it comes to denials.
21:02 It’s, it’s a huge, huge denial topic, and that’s one of the reasons why I just chose to focus on this one for this presentation, today.
21:12 That is not to say that there are not other, a theology’s or other die diagnosis that could cause altered mental status, but no, this is usually, this is actually the focus for today.
21:25 So, when it comes to encephalopathy and altered mental status, if you remember, I said that encephalopathy, often the cause of altered mental status in a lot of patients and specificity plays a huge, huge part in both aut altered mental status and encephalopathy. So say we had a patient that the provider had documented that they were all Ted.
21:54 They had a lot of clinical indicators that showed that they could have an encephalopathy.
22:01 It is the responsibility of the CDI specialists and also the coders to go a step further.
22:08 So besides just querying the provider for encephalopathy, you would also query to see if they could link that as several encephalopathy to something else that is going on with the patient, as long as there are clinical indicators in the documentation.
22:27 So what am I trying to see? The way that your query is put or is constructed, plays a huge part in the response that the providers will give.
22:40 So, if you say, um, had met, would you please clarify, if phi this altered mental status is due to encephalopathy and you don’t put anything else than they could easily Just say, yes. It’s due to encephalopathy.
22:55 But, if you ask and say, Could you please specify if this altered mental status is due to encephalopathy, due to alcohol intoxication, you know, you just go one step further as long as they’re clinical indicators in that patient record.
23:11 And the provider feels that, yes, this actually makes sense, then No, they could definitely make that linkage, and that plays a huge part in if your diagnosis would be an MCC or ICC, or nothing.
23:28 And so, that leads me to my first point, something as small as unspecified, encephalopathy, and other encephalopathy.
23:42 Already C Cs.
23:44 So, even if they did say unspecified, encephalopathy, you already have a DRG driver. But then we would like to go one step further as long as they’re clinical indicators in the note.
23:55 And so that’s the reason why I said if it’s not specified event cephalopod, if encephalopathy is not specified, please go ahead and send a query for clarification or for more specificity for more specification.
24:09 When he comes to urinary tract infection and encephalopathy, most times urinary tract infections don’t need to be treated in the hospital. It could actually be treated in an urgent care, or maybe even at home. So that’s usually not what would bring the patient into the hospital. But if a patient is presenting with a UTI encephalopathy than encephalopathy, most times, is what would cause the patient to be admitted.
24:36 And if that is what causes the patient to be admitted, if that’s the primary reason, then that becomes the principal diagnosis pair coding guidelines, toxic encephalopathy, and medication.
24:49 So this one is a little tricky.
24:51 Whenever there is, whenever, you know, there is encephalopathy that is documented as toxic encephalopathy, and maybe there is medication or a toxin that is present.
25:07 You need to ask yourself if this is a poisoning or if this is an adverse effect of the medication and sometimes you, you might need the the provider to actually clarify this through a query.
25:21 Now, if they say that toxic encephalopathy is due to poisoning or toxin, then you would sick ones the poisoning called first or the toxic effect called first before you would sequence the encephalopathy.
25:36 But if the encephalopathy over the toxic encephalopathy, is due to an adverse effect of the medication, then you would sequence the encephalopathy first And then the adverse effect called after.
25:51 Now, if we did have a patient that had acute toxic encephalopathy, due to alcohol intoxication, and this is as you mean, the provider documented it as clearly as that, then you would sick once.
26:07 The the toxic you would you would sequence that toxic effect called first and then the encephalopathy. So you wouldn’t use alcoholic encephalopathy, which is G 3 and 1.2.
26:20 You would use the the toxic effect called first and then after you would sequence the encephalopathy, due to alcohol intoxication.
26:32 Then in a case where we have intoxication delirium. So if, if you have a patient that is coming in and the patient has, has taken a lot of alcohol now is intoxicated and they are said to be delirious and the provider documented that the patient has intoxication delirium.
26:52 It’s a good idea to actually ask father if they could specify if this is a toxic encephalopathy. Because more often than not, it is a toxic encephalopathy.
27:06 And if you never ask, you wouldn’t receive, so, there is no harm in asking the provider two fathers specify if the, the intoxication delirium is caused by toxic encephalopathy due to alcohol.
27:21 And if they say that, then you have pretty much an MCC.
27:29 Next slide please.
27:35 So in the next slide for the first point, we have delirium tremens, Delirium tremens for, I’m, I’m sure we, most of us know this but delivered.
27:46 But for those of us that don’t know, delirium tremens is the term that is used to describe a patient that has been taking alcohol for a really long time.
27:58 So a chronic alcohol user and has not used alcohol for some time And now is suffering from the effects of withdrawal and with delirium tremens They could present with traumas. They could present with how those nations. So they are lit should they’re they’re really delirious I mean if you see them they’re very delirious but it’s just because they haven’t had their alcohol for some time.
28:24 So when it comes to delirium tremens it’s important to note that this is not a toxic encephalopathy.
28:31 This is because the toxin has been taken away.
28:35 The toxin bein alcohol has been taken away and so if you see delirium tremens while reviewing a patient chart, please don’t query for toxic encephalopathy. Because it’s not.
28:48 And in that case it should be coded out as F 10.231 hypoxic or anoxic encephalopathy. This one is a little tricky because even though hypoxia could cause metabolic encephalopathy.
29:05 it should not be assigned as metabolic encephalopathy.
29:09 It should it has its own code, which is G 93.1.
29:13 And if there are any confusions, you can always clarify with the provider.
29:21 … encephalopathy.
29:23 This is the one where I said, it’s seen with patients where they have severe end stage liver disease, and a lot of times it could, it’s quoted out to hepatic failure.
29:37 And it could also be fathers specified as acute, subacute, or with Koma, and, you know, the more specific they can get the better, because this one is also a huge DRG driver as well, um.
29:56 Encephalopathy due to diabetic, hypoglycaemia Yes.
29:59 So this one is the encephalopathy that you see with a patient that is present in in hypo, in a hypoglycemic state. If it was documented as metabolic encephalopathy, you can actually pick it up as a metabolic encephalopathy.
30:14 But if it was documented as unspecified encephalopathy, it’d be nice to get more specificity, some more specificity. Or if it was documented as diabetic encephalopathy, then you can actually pick it up as well.
30:31 Encephalopathy, due to a stroke, is coded out as other encephalopathy.
30:36 And for my last tip, when it comes to delirium and encephalopathy, it’s often used interchangeably and this is where the confusion and the denial start.
30:49 but, um, it’s important to note that delirium is a symptom or mental disorder while encephalopathy, on the other hand is a specific medical condition and encephalopathy could cause delirium. So, I see where the confusion is, but it’s different.
31:17 OK, so I Prepared, three case examples, because I, I wanted this to be as interactive as possible.
31:27 So I’m not just talking to myself, and the first case.
31:34 And these are actually case examples from sites that we see at …
31:40 Health, and I just felt that they, they might help, you know, drive the point home, hopefully.
31:50 OK, so for the first example, here we have a 69 year old, african american male, who has no significant past medical history, other than tobacco abuse, because he does not go to the doctor taking medications.
32:07 He was found down today by Family and brought in by MS, MS was able to obtain some history from a family member.
32:15 Apparently they had seen him last normal yesterday.
32:18 When MS arrived he was Hypertensive and Hypoglycaemic, He received IVD 10.
32:25 Here in the ED, he was found to have numerous metabolic derangements and remained altered when when he saw when I saw him, So this is a provider talking.
32:34 When I saw him, he opens his eyes, But he does not answer questions or follow commands, and it’s quite restless, sitar, who is beside sitar, who is bedside reports, he keeps trying to get up.
32:50 Hospital is service AXT to admit for further workup.
32:54 So review of systems is basically what is in the HPI.
32:59 Physical exam we see that the respiratory rate is elevated. The blood pressure is elevated as well.
33:08 He’s appearance. He is …, he is not in any acute distress. Neurologic neurologic, He opens his eyes to voice and touch but he does not answer questions or follow commands, CT brain.
33:23 Without contrast, shows that there are a traffic and chronic small vessel ischemic changes, besides that, everything else is insignificant.
33:32 So, that being the case, and based on this patient’s presentation, do you think that he’s mentation’s audit?
33:52 If you guys would like to put your responses in the chat window, I could give kean insight into what you guys think your interests are.
34:05 Thank you, Scott, It will come.
34:19 All right, we’ve got a lot of yeses. We have. Yes, he has altered. Yes. Altered mental status.
34:24 Yay.
34:26 We have a no, OK. So predominantly yeses.
34:30 So let’s go with um, let’s go with that and use that as a context for your response OK. Perfect.
34:39 So that, that leads us to the next slide, Scott.
34:41 OK, gotcha.
34:46 So if you said yes, you will be perfectly correct because it’s actually in there. It says that he is altered. Also. He did have a whole bunch of metabolic derangements, which we’ll see in the next slide. And, of course, he’s not, you know, he’s not able to answer questions. He’s able to open his eyes to voice on touch.
35:20 OK, so, here, this is actually another question.
35:24 So, and this is a question for everybody, but I’m hoping and praying that my CDI specialists and coders can see this. Um, what query opportunity would have been beneficial in this patient’s chart? And why?
35:49 Alright guys, and then put your responses in there.
35:56 Let’s give them a NaN or so mm.
36:01 I cannot stand this panel goto webinar.
36:12 Hmm.
36:19 one suggestion is to query for metabolic encephalopathy, OK?
36:25 And others to query for iron deficiency anemia, we have an anemia, anemias.
36:32 Yes, Yea. I’m happening.
36:34 OK, great. I’m happy I’m happy, because at least, you can see, besides the, the metabolic encephalopathy, and this was just, you know, while going through the chart is just something I saw. and this is one of the things that we should be able to do as CDI specialist. We’re not just looking at one diagnosis, we’re looking at the patient as a whole.
36:57 And that was why I just throw this one in there because, Scott, if you could go to the next slide please?
37:07 Thank you.
37:09 So, here, if you look at the RBC, I know the slide before, please.
37:18 So, if you look at the RV C, you see that it’s low. You see, the hemoglobin and hematocrit is, three-d.
37:25 though, and you feel look below, you see iron as though, …, low iron saturation is low.
37:33 So this is literally, I don’t know how, much obvious. it could have been that something besides, you know, the encephalopathy is going on here.
37:46 WBC’s also elevated so maybe some kind of infection could also be happening and if you look at the RTW that’s also elevated, IDW is it means … distribution with and what happens here is that whenever it’s elevated, it just means that more red blood cells are being produced.
38:08 So the buddies working really hard to replace the red blood cells that are Here, we’ll get an … right.
38:17 So there’s going to be A Difference in what the buddy started with versus what the buddies making now and that’s why that that that’s why there is.
38:29 There’s a widths if you know, to put it as simply as possible But that’s why there is that difference and that’s why the RD W is elevated. So, whenever you have an elevated our DW, this could mean that there is there could be some kind of iron deficiency present. It could be normal … or micro sits. A normal …
38:51 anemia is just or anemia that. the MCV is normal. So, you know, within the ranges of I think it’s within the ranges of 80 to 89 is normal.
39:05 I might be wrong, But please clarify that.
39:08 But now most of the MCV is normal. And the micro CITIC you would see that The MCV is low. So in this fashion the MCB is normal.
39:16 So this patient could have an iron deficiency anemia, but I guess we would never know unless we query and ask for further clarification.
39:28 Next slide, please.
39:33 OK, so we keep moving in this patient’s chart, and we see that.
39:40 there are some more labs, but I’m not going to point out the lives.
39:46 I’m not going to point out the labs. So the question here is: what lab results could have contributed to the patient’s encephalopathy? So, yes, the patient does have encephalopathy.
39:56 But besides the lab values, what type of encephalopathy do you think that this patient could be present in with?
40:15 Can we check the responses?
40:36 All right, we have, um.
40:41 Some people have submitted metabolic encephalopathy, OK?
40:46 Response, we have a hypoxic, mm, but for the most part, metabolic would be the the winner here and the response panel, OK. So, Scott, could you click on the next slide, please?
41:00 Sure.
41:05 So, yes, if you did say metabolic encephalopathy, you’ll be very correct.
41:13 Another thing that I was going to point out was the creatinine kinase. Um, if you look at that, creatinine kinase, slap vayu, it’s really high compared to what it usually is.
41:26 And that could indicate that something metabolic, besides the anemia.
41:31 And even maybe the phosphorus.
41:34 I mean, could be going on here with this patient.
41:39 Could you go to the next slide, please?
41:46 So, in the assessment and plan, the provider documented that the patient has metabolic encephalopathy.
41:53 But it’s multi-factorial.
41:55 And it he also documented that it could have been as a result of the patient’s rhabdomyolysis and possible acute anemia. So, that’s what I was trying to point out with a creatine kinase whenever you see a really high creatinine kinase like that, and maybe the patient has been down on the ground, which is what the spatial was presenting with. The patient had been down on the ground for quite some time.
42:20 The muscle can start going through some lysis process and could develop rhabdomyolysis.
42:33 And in this types of patients, you would no give them fluids to help bring down the creatinine kinase so that they don’t go into acute kidney injury. And then if you look further down in the assessment and plan, you see that the provider did document.
42:51 that the patient has severe anemia, But then it’s unspecified. He didn’t see what type of anemia.
42:58 So that’s why, you know, like I said, when you’re looking at the patient, you’re looking at the patient as a whole.
43:05 And this is one of the reasons why we encouraged our CDI specialists, too, look at, you know, even if, even if you’re reading the chart, for example, in three M, you should also be looking at the lab values on the side, so that you’re not just reading what the chart sees because you could miss, you could miss some critical secondary diagnosis. So that’s why you need to look at the lab values. So that you’re also picking up on other diagnoses that you would query the provider for.
43:39 Slide, please.
43:43 OK, so in the second example, here we have a 38 year old male, with a history of tobacco use and alcohol abuse, he is admitted to the ICU after being found unconscious at the gas station and brought to the ER by MS.
43:59 The patient is not able to provide history at this time, and currently there is no family or friend information available.
44:07 The patient was apparently gamblin at the gas station and drinking. When he lost consciousness.
44:13 It is unknown whether he had any priest in Kabul episodes.
44:18 On arrival to the ER, he was initially comatose and intubated for airway protection.
44:24 Work up with CT, head and neck was on revealing except for spinal canal stenosis.
44:30 There was no bleat evident Labs were on revealing except for an alcohol level of 316.
44:38 Urinary drug screen is pending, Yd noises report that after incubation the patient became very agitated and tried to pull out his tube, and appeared that he was non vocal.
44:52 He was then sedated heavily with purple fall.
44:56 … cannot be obtained due to the patient’s mental status.
45:00 Physical exam shows a respiratory rate of 26, which is quite elevated.
45:06 Blood pressure is slightly elevated, especially at the bottom and died.
45:13 Generally the patient is incubated and Sedated.
45:16 Neurologic shows that the patient is heavily sedated and does not wake up to verbal or painful stimuli. Withdraws from sterile Rob cuffs, cough sweat sanctioning of ET tube. Not localizing to pain. Currently CT brain shows no acute intracranial abnormality.
45:36 So my question here is what lab result could indicates that the patient has a possible toxic metabolic encephalopathy.
45:58 OK, let’s see what the group is saying.
46:12 Right.
46:14 So we have looks at the consensus here Yes, Mariana, you could write up your answer there. Looks like the consensus here is the blood alcohol level of 316.
46:24 Hmm, hmm, hmm, hmm, hmm, hmm, hmm, hmm, Yes, and that would be the correct answer as we see in the next slide.
46:38 So, could we go to the next slide, please?
46:44 All right, so, here, the last example is from another facility, Here.
46:50 The patient, presented early this morning at 6 30 AM, had a significant fall and fractured his right hip.
47:01 It does have a history of alcoholism and chronic …, and he and he is sodium, was 115 at the time of evaluation past medical history. His dad died in 20 14 and his mom died last year from Corvette, and he has struggled with depression and has had some problems with alcohol and, more recently, problems with ….
47:25 He has been having some passing out spells are essentially from also static hypotension and syncope along with excessive alcohol use.
47:36 Social history shows that he, he’s a non smoker, with a significant alcohol history. He is a retired state worker and farmer, and again, drinks probably a pint of vodka a day.
47:53 Review of systems.
47:55 He had a mechanical, full, landed on his hip and was not able to get up.
48:00 He complains of right hip pain. He has some tremors.
48:04 Again, he said he had been drinking the night before.
48:08 He says he drinks two large glasses a day, which his wife equates to a pint.
48:15 In the physical exam in the neurologic section, he dies, have some mild trauma’s consistent with possibly.
48:25 Early SDR exists from withdrawals, assessment, and plan.
48:30 Here, the provider documented a whole bunch of diagnoses, but the one that I wanted us to focus on was Number two, which Say’s Excessive alcohol use we will watch for ….
48:48 So, next slide, please. All right.
48:51 So, from the patients history, in the previous slide, what condition do you think that this patient could be presenting with due to his excessive alcohol use?
49:20 Let’s see what we have here.
49:28 DT’s.
49:30 So, the consensus here is B, alcohol withdrawal delirium tremens Perfect. And that would be the answer the group.
49:39 Next slide please.
49:43 All right.
49:44 So, based on your knowledge of CDI approach to encephalopathy, would delirium tremens be considered a type of toxic encephalopathy and why?
50:16 So the question that doctor … put out there is, would this be considered a type of toxic encephalopathy, yes or no?
50:23 And we have.
50:27 Slew of nos came in.
50:30 Perfect. And can anybody say why it wouldn’t be a toxic encephalopathy?
50:36 Right?
50:48 We have, it’s not due to drugs, is one answer.
50:53 OK, and it says, no, it’s due to lack of alcohol. Not too much drug toxicity.
50:58 OK, Ernie, All right.
51:06 Next slide, please.
51:11 So if you said no, then that would be correct.
51:13 And that’s perfect because if you remember, we said in the initial slides that withdrawal delirium also known as delirium tremens, it is not a toxic encephalopathy. Because we have taken away the toxin, which was alcohol. And in that case, the code, the code in four this will be different. It wouldn’t be an encephalopathy code. And just to re-iterate, again, delirium is a Mental Disorder and cephalopod.
51:41 The is a medical condition, and the next slide, please.
51:55 And just to briefly summarize everything that I have said, EMS, also known as Altered Mental Status, It is a symptom code. It is an R code. It’s not a diagnosis.
52:11 Some people think it’s a diagnosis, but it’s not.
52:14 And, you know, whenever you see that, with A, in a patient’s chart, please, as a CDI specialist or a quarter, please do do your due diligence to query the provider to see if they could be more specific, especially, if there are clinical indicators in the, in the documentation or in the patient’s chart.
52:40 It says here, the hallmark of encephalopathy is an altered mental state and, if you remember, I said that encephalopathy is one of the most common causes of a patient coming in with an altered mental state. So, yes.
52:56 If you see altered mental status and maybe there are more clinical indicators, please go ahead and query and no encephalopathy is also a clinical diagnosis. You know, when we, say, Clinical diagnosis, we mean that you can look at the patient from the patient’s physical history and, you know, their HPI and everything. They’re telling you, you can, actually make your diagnosis.
53:19 You don’t really need to get all this labs to make the diagnosis.
53:25 And that being said, this is one of the reasons why this diagnosis of encephalopathy opens it up to a lot of denials.
53:33 And this is why, um, it’s important to also do a clinical validation whenever you see encephalopathy documented in the patient’s chart.
53:46 Go ahead and check for clinical indicators to back up this diagnosis. I remember there was a denial that I saw on time and they stated that the patient had encephalopathy.
53:59 But then in the physical exam, you know, they said that the patient’s mental status was at baseline.
54:06 So already that is conflicts and that is not going to work. You know, it’s not it’s not it’s going to definitely get denied.
54:14 And so that’s why we encourage the CDS this, too, go back and check and make sure that all the clinical indicators or, as many as possible are present in the patient’s document in the patient’s chart, um, hmm.
54:32 For to be able to strengthen your documentation or the provider’s documentation of encephalopathy, check to see if the provider has linked the encephalopathy with the, you know, underlying cause of encephalopathy.
54:47 And if they haven’t, you could query makes sure that the clinical indicator spreads and, and, of course, make sure that the chart is telling one consistent story.
54:58 So no. It won’t be proper for us to just capture encephalopathy. That is being mentioned only one time, maybe in the discharge summary.
55:09 We need to try to see if the providers can carried, you know, through their note. and then also in the discharge summary.
55:18 I know it could be hard sometimes, but, you know, if, if, if you can accomplish that as a CDI specialist or COTA, then this will be perfect and this would decrease the possibility of having a denial of this diagnosis.
55:35 Um, and the next slide.
55:43 Please.
55:48 And so, there’s other resources that were used for this presentation. And.
55:56 Any questions? If you have any questions, I think we have, like, maybe, four minutes left or so or something.
56:03 Yeah, we have a we have a few minutes. Good job.
56:07 Thank you for that presentation.
56:09 My own 2% is that encephalopathy was probably the most challenging diagnosis that I intersected with my formatting coding days hmm, hmm, over 20 years ago.
56:22 And over 20 years later, it’s still tied up in the list When it comes to problematic diagnosis is just that the clinical perspective on encephalopathy does not jive with the way that it’s classified in our in our code sets. It says, yeah, if there’s a disconnect there.
56:45 And because of that disconnect, we try to bring it through.
56:49 It seems like incessant queries.
56:53 Rabia was like that as well.
56:54 It looks like the physicians are slowly phasing out that that term as a synonym for sepsis, but nonetheless encephalitis still hanging out there and torturing us.
57:05 But let’s see if there’s any other questions I will see there.
57:09 Will the recording be available for providers? Yes, it is.
57:13 Will we send out CEUs, please go to our Webinars page and you’ll be able to download your CEU there. That’s the case.
57:22 Um.
57:23 That’s the case after every webinar.
57:26 We have A Great presentation there, doctor Koh. So thank you.
57:30 Thank you.
57:32 There’s a question that says, Is hepatic encephalopathy, a type of metabolic encephalopathy?
57:37 I’ll put that up there.
57:40 That’s a great question. It’s not it. Hmm, it’s not quoted out as the same.
57:47 It’s, it’s kinda different with the code, said, it’s not cut it out.
57:50 So that to be the same thing the presentation is, it looks like a metabolic encephalopathy, especially because of the elevation of the ammonia levels. But it’s not coded out to be the same.
58:03 In and clinical in the clinical world, it would be a metabolic issue. But in the coding world, it would not be quoted out as the same.
58:14 So here’s a question.
58:19 At what point do you just consider the encephalopathy to be part and parcel of the underlying condition?
58:28 And when do you take it the next step and pursue that as a secondary diagnosis?
58:35 That’s a great question.
58:37 That’s a loaded question. I’m trying to break it down in my head.
58:40 They’re all loaded. It’s, I’m trying to break this one, yeah. I think that just a bit is that sometimes it’s used interchangeably with altered mental status and you see that people come in a little bit.
58:52 No whacked out, um, transient in nature, and no resolve really on its own.
58:58 And other times, it’s kind of a little bit more than that.
59:01 You’re reporting as a secondary diagnosis and sometimes that transition point, whether it’s at will, where it is or pursue it as a secondary diagnosis is unclear mm.
59:11 So, I think, in that case, you know, if we have, if we Think about what the secondary diagnosis is, it is something that it’s a diagnosis that is evaluated, or that is treated, or that would increase the length of stay of the patient.
59:28 So, whenever you see that being done, then that’s when you can start considering it as something, too, you know, pay attention to.
59:37 So, if the altered mental status is being treated, or if it’s, if it’s being evaluated in some sort of way, maybe they are doing an EEG or something, then yes, that would count as a secondary diagnosis OK.
59:54 OK, and I think, Vicki, following up on that question, she provided an example where there’s A encephalopathy, that’s kind of an acoustic echo.
60:06 Post users.
60:07 Yeah, so, OK.
60:13 We are out of, we’re out of time here. Thank you, everybody, for your time and interaction, thank you for your patience.
60:19 We tried something a little bit different year, where we added some Q and A That adds layer of complexity here, so thank you for your patience, as I know, clunked around the UI, trying to keep things moving, so appreciate it.
60:34 For anyone that was unable to download the presentation on the couple people noted that it will be sent out in the follow-up e-mail. So when you get that e-mail, it should have a link to the should include the presentation there.
60:48 So that should make you hope. Thank you, everyone, for your time. Our next webinar will be next month, and have a great day. Have a great week.
60:59 Thank you.