Using the Right ICD-10 Codes to Document Encephaloopathy

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

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2. Encephalopathy refers to any brain disease that alters brain
function or structure. Medical coding companiesoften come across
the diagnosis of this disorder, for which they need to be up-to-date
with the latest medical codes related to this.
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3. Toxic encephalopathy
Metabolic encephalopathy
Anoxic encephalopathy
Hepatic encephalopathy
Hypertensive encephalopathy
Acute encephalopathy
Chronic traumatic encephalopathy (CTE)
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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
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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
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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
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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
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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
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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
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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.
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Documentation Tips

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