Q&A: Encephalopathy due to UTI versus metabolic encephalopathy due to UTI

Q: We’re struggling with one particular aspect of encephalopathy. Coding Clinic, Second Quarter 2018, pp. 24-25 advises coders to assign G93.49, Other encephalopathy, for documentation of “encephalopathy due to urinary tract infection (UTI).” Can code G93.41, Metabolic encephalopathy, be assigned for provider documentation of “metabolic encephalopathy due to UTI?” For cases involving documentation of unspecified encephalopathy (CC) due to a UTI, is it appropriate to query for further specificity of the type of encephalopathy, such as metabolic encephalopathy (MCC)?

A: Metabolic encephalopathy is caused by such things as fever, dehydration, electrolyte imbalance, hypoglycemia, hypoxemia, any infection, and organ failure. It is always appropriate to query for the specific type of encephalopathy whenever it is caused by any of these conditions.

In the case of a UTI, it would be metabolic encephalopathy even in the absence of fever or other specific findings since many susceptible patients, especially the elderly, experience encephalopathy with any infection. Whenever “metabolic encephalopathy” is documented, code G93.41, Metabolic encephalopathy, should be assigned.

Editor’s note: Richard Pinson, MD, FACP, CCS, answered this question. Pinson is the co-author of the CDI Pocket Guide and the Outpatient CDI Pocket Guide: Focusing on HCCs. He and Cynthia Tang, RHIA, CCS, principals at Pinson and Tang, LLC. Contact him at rpinson@pinsonandtang.com.