Physicians need to document all the necessary details about the encephalopathy to ensure it is coded and reported accurately.

1. www.outsourcestrategies.com

2. Encephalopathy refers to any brain disease that alters brain
function or structure. Medical coding companies often come across
the diagnosis of this disorder, for which they need to be up-to-date
with the latest medical codes related to this.
www.outsourcestrategies.com

3.  Toxic encephalopathy
 Metabolic encephalopathy
 Anoxic encephalopathy
 Hepatic encephalopathy
 Hypertensive encephalopathy
 Acute encephalopathy
 Chronic traumatic encephalopathy (CTE)
www.outsourcestrategies.com
Common Types of Encephalopathy

4.  History and physical exam
 Lab findings: CBC, liver function tests, ammonia and blood glucose
levels, lactate levels, kidney function tests, blood cultures, virology
testing, and or ABGs
 Neuroimaging studies
 EEG findings
www.outsourcestrategies.com
The diagnosis is based on

5.  Usually irreversible, this disorder is caused by the interaction of a
chemical compound with the brain
 Substances that cause the condition include drugs, radiation, paints,
industrial chemicals, and certain metals solvents, medications or drug
ingestions, radiation, paints, industrial chemicals, and certain metals
www.outsourcestrategies.com
ICD-10 Codes to Document Encephalopathy
G92 - Toxic Encephalopathy

6.  If blood flow to the brain is blocked or slowed due to a blood clot
 Due to stroke, heart attack, lung disease, prolonged exposure to
certain poisons or toxins, or any incident that compromises breathing
www.outsourcestrategies.com
G93.1- Anoxic Encephalopathy
Also referred to as hypoxic encephalopathy, it is caused by brain damage
due to lack of oxygen. Anoxic brain damage can occur

7.  Acute encephalopathy is caused by either a direct injury to the brain or an
illness
 Correction of these abnormalities can reverse the condition
 It may be further identified as toxic, metabolic, or toxic-metabolic
www.outsourcestrategies.com
G93.40 - Encephalopathy, Unspecified
 Caused by underlying conditions such as infections, toxins, or organ failure
 Usually resolves when the underlying chemical imbalance is restored or
offending infection/toxin is eliminated
G93.41 - Metabolic Encephalopathy

8.  The condition is caused by extreme high blood pressure levels
 Usually leads by severe headache and followed by convulsions, coma or a
variety of transitory cerebral phenomena
 Treatment aims at decreasing blood pressure and most often the effects are
reversible
www.outsourcestrategies.com
I67.4 - Hypertensive Encephalopathy

9.  It is characterized by personality changes, intellectual impairment, and a
depressed level of consciousness. Coma may or may not be present
 Appropriate treatment and compliance with protocols could reverse the
condition
 Around 30% of patients with end-stage liver disease experience significant
encephalopathy
www.outsourcestrategies.com
K72.90 - Hepatic Failure, Unspecified without Coma
Observed in patients with cirrhosis or liver disease, this syndrome can harm
the liver and the organ cannot remove toxin from the blood

10.  The documentation should include terms like “toxic encephalopathy” or
“metabolic encephalopathy” and describe what the toxin, poison, or
metabolic issue is
 Details such as types of condition, description of symptoms, and
underlying cause should be documented
 Other signs and symptoms not associated routinely with a disease
process should also be coded when present
 If a patient has both delirium and encephalopathy at the same time, both
due to the same cause, both can be coded if each required their own
diagnostic workup or interventions.
www.outsourcestrategies.com
Documentation Tips

11. CONTACT
Headquarters:
8596 E. 101st Street, Suite H Tulsa, OK 74133
Main: (800) 670 2809
Fax: (877) 835-5442
E-mail: info@managedoutsource.com
URL: http://www.outsourcestrategies.com