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Encephalopathy Coding: Challenges and Solutions

By Leigh Poland

June 13, 2024

Encephalopathy is a broad term that describes abnormal brain function or structure that can lead to an altered mental status, leaving the patient confused and not acting like they usually do. It can happen when there's been a change in the way the brain works or a change in the body that affects the brain. Due to its prevalence, it is common that it arises as a condition that requires proper medical coding

There are many types of encephalopathy, including metabolic, toxic, anoxic, hypertensive, and Wernicke's encephalopathy. To accurately code and identify clinical documentation improvement opportunities for encephalopathy, it is crucial to understand the characteristics of the different types. For instance, metabolic encephalopathy is caused by a buildup of toxins in the body, whereas toxic encephalopathy is caused by exposure to toxic chemical substances. Anoxic encephalopathy occurs when the brain is deprived of oxygen, while hypertensive encephalopathy is caused by high blood pressure. Wernicke's encephalopathy is a type of brain injury most common in those who drink alcohol excessively, which causes a lack of thiamine, a type of vitamin B.

Type ICD-10-CM Code
Hypertensive encephalopathy I67.4
Toxic encephalopathy G92.8 (other toxic encephalopathy)
G92.9 (unspecified toxic encephalopathy)
Metabolic encephalopathy and encephalopathy septic G93.41
Anoxic encephalopathy G93.1
Wernicke's encephalopathy E51.2

Medical coders must also understand the specific symptoms associated with each type. For instance, symptoms of metabolic encephalopathy include confusion, lethargy, and seizures, while symptoms of toxic encephalopathy include tremors, muscle weakness, and loss of consciousness. Symptoms of anoxic encephalopathy include memory loss, confusion, and seizures, while symptoms of hypertensive encephalopathy include headache, nausea, and vomiting. Symptoms of Wernicke's encephalopathy include confusion, ataxia, and vision changes.

There are differences medical coders need to understand between acute versus chronic encephalopathy. Coding and documentation improvement challenges can arise when encephalopathy is documented alongside conditions such as a patient with dementia, a patient involved in a cerebrovascular accident (CVA), or patients with specific conditions such as urinary tract infection, hypoglycemia, or sepsis. There are also differences to note related to poisoning and adverse effects as well as alcohol use.

In addition to understanding the different types and symptoms of encephalopathy, medical coders must be aware of the query opportunities and coding clinics surrounding this condition. It is important to work closely with physicians and patients to determine with specificity the cause and duration of encephalopathy. The documentation should include information such as when the diagnosis started, when the symptoms started, and how long the symptoms have lasted.

Accurate medical coding is critical for proper documentation and treatment of encephalopathy. Medical coders must have a thorough understanding of the different types and symptoms of encephalopathy, as well as the official coding resources and guidelines. Contact us for more information about supporting your team with our medical coding services, technology, and software related to code updates and guidelines.

Leigh Poland

Leigh Poland RHIA, CCS


Leigh has over 20 years of coding experience and has worked in the coding and education realm over the last 20 years. Her true passion is coding education making sure coders are equipped to do their job accurately and with excellence. Academically, Leigh has graduated from Louisiana Tech University with a Bachelor of Science. Leigh has had the opportunity to present many times in the past at the AHIMA, ACDIS, and AAPC National Conventions. She has been a guest speaker on AHIMA webinars and has written several articles that were published in the AHIMA Journal. Leigh has traveled the US and internationally providing coding education.

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