Note from the Instructor: Encephalopathy tips

CDI Blog - Volume 11, Issue 135

Sharme Brodie,

By Sharme Brodie, RN, CCDS

Recently, I was asked an interesting question about querying for the diagnosis of encephalopathy. The student asked whether it was required for a patient to return to their mental status baseline prior to the CDI specialist querying the provider for the diagnosis of encephalopathy.

A couple things need to be addressed before we can fully answer this question. First, what is a patient’s normal baseline? When reviewing medical records, I’ve often found that documentation regarding a patient’s baseline or normal mental status lacking. This can be even worse if a patient is what we refer to as a “frequent flyer,” well-known to the staff at a facility because of their repeated visits.

In nursing school, I learned that every time we document in a patient’s medical record, we should do so as if it’s the first time we’ve met them. The fact is, however, that we document less and less about these patients who are known to be frequent flyers. We assume everyone who takes care of the patient knows everything there is to know about their medical conditions. Unfortunately, this can lead to missing really important information—like changes in their mental status or general behavior.

Another problem can result from increased expectations regarding productivity. Providers are expected to take care of more patients now, providing the same excellent care as ever. By keeping their documentation to a minimum, they can save time that can be spent elsewhere.

EHRs can also lead to sparse documentation. With the addition of dropdown boxes, it has become easier to check a box on a patient’s assessment than type in the information. This is where a CDI program can step in and show physicians how specific information documented in a patient’s medical record matters, even when it may not seem to.

Secondly, does your facility have an internal policy that requires specific information or certain clinical indicators be present in the medical record prior to querying a provider for certain diagnoses? Some facilities have trouble with certain conditions and develop what are known as “best practices” for these types of conditions. This would ensure that everyone involved in the process agrees on the information or clinical indicators needed to support a query for a given diagnosis or set of symptoms.

Encephalopathy is often one of the conditions that require special attention. If your facility does have best practices in place for the diagnosis, ask whether all types of encephalopathy are treated the same way. I spent some time researching the subject and, in the end, I could not find any authoritative source that stated a “return to baseline” was required prior to querying a physician for the diagnosis of encephalopathy. You need to be aware, however, of any internal policies and follow any rules set forth by your facility.

These types of rules could also be part of education supplied by a specific consulting company employed by your facility, so as a CDI specialist or coder, we need to be aware of these types of policies and comply with them, but trust your gut. If for some reason you feel something may be noncompliant, ask questions such as where the information came from.

Now that we’ve covered some of my initial questions and concerns, let’s spend some time talking about what encephalopathy is.

Encephalopathy is a broad term used to describe abnormal brain function or brain structure. The hallmark of encephalopathy is altered mental status. The abnormality may be transient, recurrent, or permanent. There are numerous types of encephalopathy and brain disorders with a variety of different etiologies. Some types are permanent, some are temporary. Depending on the type and acuity of the encephalopathy, it could affect whether the patient will ever return to a “normal baseline.”

The diagnosis of encephalopathy starts with the history provided by the patient or family. We will have a better understanding of the possible etiology based on the information provided about the patient’s symptoms. When did they start? How long did they last? Did they wax and wane? The patient’s past medical history and history of present illness can also provide clues as to the type and cause of the encephalopathy.

Lab tests, including complete blood counts or chemistry tests, including electrolytes or alcohol and drug screening, can also provide information. Imaging studies such as x-rays, computerized tomography (CT), and magnetic resonance imaging (MRI) can also be helpful. A CT/MRI may be unremarkable when the abnormalities of the brain are functional not structural. A lumbar puncture could also be useful in determining whether there is infection, bleeding, or inflammation present. Other testing may be appropriate depending on the clinical situation and/or the provider’s suspicions.

Treatment of the encephalopathy, including specific medications, will vary depending on the cause of the encephalopathy. Some encephalopathies are preventable (such as hepatic encephalopathy due to liver failure related to alcoholism). Other types of encephalopathies, such as congenital or related to acute trauma, are unpreventable. Some encephalopathies may be easily reversible, while others can progress, causing permanent structural damage to the brain. A patient’s outcome depends on the underlying cause of the encephalopathy and it’s potential for treatment.

Some of the different types of encephalopathy include:

  • Metabolic (G93.41): Causes include fever, dehydration, electrolyte imbalances, acidosis, hypoxia, infection, and organ dysfunction.
  • Toxic (G92): Causes include effects of non-medicinal drugs and toxins, but not medications.
  • Toxic-Metabolic (G92): Suggests a combination of toxic and/or metabolic factors
  • Septic (93.41): A clinical term that represents a manifestation of severe sepsis.
  • Hepatic (K72.90): Describes a spectrum of neurologic impairment in patients with severe end-stage liver disease, such as altered mental status, confusion, disorientation, inappropriate behavior, combativeness, gait disturbances, and/or altered level of consciousness ranging from drowsiness to deep coma. An elevated level of neurotoxic blood ammonia confirms the diagnosis.
  • Hypertensive (I67.4): An acute or subacute consequence of severe hypertension marked by headache, obtundation, confusion, or stupor, with or without convulsions. Papilledema may be noted.
  • Hypoxic or anoxic (G93.1): A permanent chronic brain damage due to sustained hypoxia.
  • Hypoxic ischemia or HIE (P91.60): Applies to neonates and is an acute or subacute brain injury due to oxygen deprivation at delivery. Seizures are common manifestation.
  • Chronic traumatic encephalopathy (CTE) (F07.81): The term used to describe brain degeneration likely caused by repeated head traumas. CTE is a diagnosis only made at autopsy by studying sections of the brain. Some symptoms of CTE are thought to include difficulties with thinking (cognition), physical problems, emotions, and other behaviors.

In summation, acute encephalopathy is the underlying cause of an acute generalized alteration of mental status for most patients admitted to hospitals. It can be either the principal diagnosis, or a secondary diagnosis. Whether a patient is expected to return to their “normal” baseline will depend on the type of encephalopathy they are diagnosed with.

Certain types of encephalopathy such as metabolic, septic, and hypoxic should return to baseline once the underlying etiology is corrected. Encephalopathy caused by a stroke or vascular encephalopathy or trauma would not be expected to return to the patient’s “normal” baseline. It depends on the type of encephalopathy and underlying etiology, whether the encephalopathy causes permanent or transient damage to the brain.

Editor’s Note: Brodie is a CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit

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ACDIS Guidance, Clinical & Coding