Q&A: CVA and stroke related to encephalopathy

Q: Often, we get caught up on some clinical indicators that potentially introduce encephalopathy, for example, if patient has vascular dementia or other structural issues that might contribute to encephalopathy. Can you help provide some guidance here?

A: This is a very debatable topic in our field and I’m glad to have the opportunity to address it. As of right now there is a Coding Clinic, Second Quarter, 2017, which states that with a cerebrovascular accident (CVA) (and they were really talking about lacunar infarcts) you can code encephalopathy.

However, this is one where I recommend that you proceed with caution as we/I err on the side of being conservative.

As long as you have a dementia baseline and you have a source for the encephalopathy process, such as an infection, and that source is being treated, and the patient returns back to their dementia baseline, you code both diagnoses as long as the documentation clinically supports both. In the case of encephalopathy superimposed on dementia, the provider’s documentation must be crystal clear with a well-documented baseline.

CDI professionals might try to word a query as “encephalopathy superimposed on [type of] dementia,” and whether it was resolved or not. Again, in the clinical indicators, make sure to include the signs of the mental alteration with the baseline and the return to the patient’s baseline. If you do not have a baseline for the dementia, it will be hard to prove the encephalopathic process exists.

Editor’s note: Dawn R. Valdez, RN, LNC, CDIP, CCDS, CDI manager of education at Ardent Health Services in Nashville, Tennessee, answered this question during the August 7, “ACDIS Conference: Clinical and Coding Highlights” webinar series. Contact her at Dawn.Valdez@ardenthealth.com.