Data & Reimbursement Committee Coding Tip: Encephalopathy & COVID-19

May 2021
By Erin Leighton, RHIT

Encephalopathy is a condition that affects the brain and can alter a patient’s mental state. Common symptoms include: confusion, memory loss, inability to focus, and personality changes. There are many causes of Encephalopathy, many of which are linked to other conditions or diseases. Clinical evidence may be supported by blood and urine tests, spinal fluid tests, CT, MRI, EEG, etc. Did you know that it can co-occur in patients who are sick with COVID-19?

One of the best ways to ensure you are capturing this diagnosis as you code is to review the emergency department record of the patient. As you review the ED encounter, remember to ask yourself:

  1. Was it present on admission?
  2. Was it documented by the clinician and supported by clinical evidence?
  3. Is the type or cause of the condition documented?

It is important to look for the type of encephalopathy that is presenting in the patient whenever possible and to identify it with the appropriate code. Why? This can often be the difference between a CC and MCC and will account for those encounters which require higher resource intensity to care for the patient.

Remember, if COVID-19 is also documented and appears to be the principal diagnosis, use the code U07.1 (COVID-19). Next, select your code for Encephalopathy, provided there are no other conditions that need to be sequenced first. Here are some of the options that can be coded for Encephalopathy so long as they are appropriately documented by the clinician:

  • G92: Toxic encephalopathy
  • G93.1: Anoxic brain damage, not elsewhere classified
  • G93.41: Metabolic encephalopathy
  • I67.4: Hypertensive encephalopathy
  • K72.90: Hepatic failure, unspecified without coma
  • P91.60: Hypoxic ischemic encephalopathy [HIE], unspecified

May 2021 Coding Tip Source