According to ICD-10, gone are the days when you had to be chemically dependent on a substance in order to experience withdrawal (I will defer my criticism of that logic to another time):
There is even F19, “other psychoactive” abuse with withdrawal series.
Given the codes above, obviously not everyone who is confused or experiencing delirium has perceptual disturbances, etc. related to a substance. A patient may have “toxic encephalopathy,” no matter what some of the consultants may tell you. Logic would dictate that at least sometimes, these CC level substance codes are more appropriate.
When would these codes be more appropriate? When the symptoms are directly related to these specific neuro-active substances, and when the symptoms are somewhat expected as known effects of such medications (or the withdrawal of same).
When the reaction is not just an adverse effect or part of withdrawal situation, or the dosages/blood levels/tox screens were extremely high and symptoms were well above or worse than what routinely be seen, then you may begin to build your clinical rationale for moving to toxic encephalopathy. If you do so, the expectation is that the resource utilization of the facility would be at a level much higher than that of the routine care normally provided for mild withdrawal, or adverse reactions of prescription opioids/sedatives/anxiety meds. Look for a transfer to a higher level of care, more frequent neuro checks, intensive respiratory and vital checks, a sitter, heavy sedation, possibly airway protection, restraints, a protracted (48 hours or more) period of extreme confusion, possibly violent/aggressive behavior, and some context that this is not just care for a routine detox or adverse reaction, somewhere in the physician’s documentation.
Quickly resolving episodes of confusion in response to neuro-active medications is probably better identified as the drug-induced delirium due to known physiological cause (F05) category. Oddly enough, delirium of unknown etiology indexes to R41.0 “Disorientation” (a non-CC), while simply having “acute confusional state” will index to F05 (a CC). We know what some auditors will do with that; suddenly, all unspecified delirium is cured, and everyone in the U.S. is in an acute confusional state!
If, however, the substance is not a neuro-active drug (such as an antibiotic) and the reaction is somewhat atypical, Coding Clinic does allow a move towards toxic encephalopathy (even if it is labeled as an adverse reaction).
As always, this is complicated. If the encephalopathy is attributed to a disease process, but not a metabolic or toxic issue specifically, it will be reported as “other” (G93.40), and septic is G93.41 (metabolic).
Somehow, diabetic hypoglycemia (according to Coding Clinic) can still be reported as metabolic encephalopathy (I personally don’t recommend doing this if it was rapidly resolved with standing orders, with no additional workup or lasting impacts, but that is opinion, not guidance), while a patient with hepatic encephalopathy is still only reported as having cirrhosis (tell me which of those two requires more hospital resource utilization to fix!)
Coding in the post-acute care world has taken on a new significance in the past five years. For those of us who are coders, this
External audit volume more than doubled in 2024 over 2023 while total at-risk dollars increased fivefold to $11.2 million, impacting healthcare provider organizations’ cash flow
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 ICD10monitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
