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What is the average number of provider’s reviewed for E/M compliance

I am being asked for information regarding productivity of our auditors. Does anyone know what the average number of provider’s reviews for E/M and compliance elements per auditor per year. I am having difficulty finding those numbers and thought perhaps someone has some information or reference for me. Thank you

Medical Billing and Coding Forum

Health Plans Get a Reprieve on HIPAA Compliance

The “Administrative Simplification: Certification of Compliance for Health Plans” proposed rule has been withdrawn. Although health plans still must comply with HIPAA electronic transaction regulations, they do not have to certify their compliance or else be fined. HHS Backs Down on Certification The U.S. Department of Health and Human Services (HHS) published the proposed rule Jan. 2, […]
AAPC Knowledge Center

How is your HIPAA auditing and compliance government entity doing?

OIG tells OCR to establish its permanent audit plan. OIG officials called OCR’s oversight of the HIPAA Privacy Rule "primarily reactive." It investigates possible noncompliance primarily in response to complaints. Establishing a permanent audit program would help OCR "proactively assess possible noncompliance from covered entities."

So when should entities expect to see the permanent audit program rolled out? Mac McMillan, FHIMSS, CISSM, cofounder and CEO of Cynergis Tek, Inc., Austin, Texas, and Phyllis A. Patrick, MBA, FACHE, CHC, CISM, founder of Phyllis A. Patrick and Associates, LLC., Southport, North Carolina, each say they expect the full program to hit the streets in early 2016. However, Patrick says, "I will believe it when I see it."

Covered entities, she adds, should always be ready for an audit. 

This article was originally published in Briefings on HIPAA. Subscribers can access the full article in the January 2016 issue. – HIM-HIPAA Insider

Compliance Question

I have a BAA with a web-based EHR/RCM and with its affiliated scheduling system. The EHR/RCM uses a specific clearinghouse to process my claims and the scheduling system uses a specific company to process patient payments (debit/credit/ACH). The EHR/RCM has a BAA with the clearinghouse. The scheduling system has a BAA with the payment processing vendor.

My question is: In order to remain compliant, do I need a separate BAA with the clearinghouse and the payment processing vendor?

Thanks for any advice!

Velocity Medical Billing

Medical Billing and Coding Forum

Seeking compliance individual to assist office

We are looking to outsource a compliance person to help get our office in order. We need someone to come in and evaluate our practice for possible compliance issues and steer us in the correct direction. Does anyone have any suggestions of someone that might be considered for this? We are in Alabama so would certainly love to find someone close to our area.

Thank you in advance!!

Medical Billing and Coding Forum

Bolster billing compliance: Implement a Medicare Part A triple-check process

Bolster billing compliance: Implement a Medicare Part A triple-check process

Medicare billing is a domain rife with payer offshoots and evolving regulations that can be difficult to navigate without a strategy to weather claim scrutiny and withstand the gaze of CMS’ various auditing contractors.

Enter the triple-check process, a time-tested internal auditing strategy used by proactive long-term care providers to facilitate billing accuracy and compliance the first time a UB-04 claim form is submitted. As its name suggests, triple check is a layered verification process that involves staff members from billing, nursing, and therapy departments?the three core disciplines required to submit a clean claim. But this sturdy foundation is also pliable, allowing a facility to easily adapt the procedure to the various types of claims it files.

Read on for an expert iteration of the triple-check process, which is modified from the HCPro book The Medicare Billing Manual for Long-Term Care, written by Frosini Rubertino, RN, BSN, C-NE, CDONA/LTC. This specific triple-check procedure is designed to mobilize key staff to ensure accuracy and timely submission of Part A claims.



Each month, the SNF will collect all Medicare Part A billing information ready for submission and enlist the following individuals to carry out their designated roles in verifying the accuracy of these items: administrator, director of nursing, MDS coordinator, facility rehab director or designee, business office manager, medical records personnel, and central supply staff.

The following is a breakdown of each of these staff members’ responsibilities in the triple-check process:

Business office manager and medical records personnel

  • Verify that the qualifying stay information recorded on the UB-04 aligns with that on the medical records face sheet.


Business office manager

  • Verify that each resident has benefit days available in the HIPAA Eligibility Transaction System.
  • Verify the admit date on the UB-04 aligns with the date in the manual census log.
  • Verify covered service dates listed on the UB-04 align with those in the Medicare and manual census logs.
  • Verify that a resident’s financial file contains a signed and completed Medicare Secondary Payer form whenever applicable.


Business office manager and MDS coordinator

  • Verify that ADLs are correct and are supported by documentation. Confirm that staff have coded all other contributory items (e.g., mood, IVs).
  • Verify that ARDs on each MDS align with the occurrence dates found at form locators (FL) 31?34 on the UB-04.
  • Verify that the RUG level listed on each MDS aligns with that found at FL 44 on the UB-04.
  • Verify that the assessment type for each MDS aligns with the modifier found at FL 44 on the UB-04.
  • Verify that the number of accommodation units listed on the UB-04 aligns with the assessment type for each MDS. Verify that the total number of accommodation units aligns with corresponding covered service dates.


Facility rehab director, MDS coordinator, and business office manager

  • Verify that physical therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes documented in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that each principal diagnosis is accurate, that all secondary diagnoses support skilled care, and that every ICD-9 code corresponds to an appropriate diagnosis.
  • Verify that occupational therapy minutes recorded on the daily treatment grid align with those in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.
  • Verify that speech therapy minutes listed on the daily treatment grid align with those noted in the service log. Align the days and minutes in the MDS with those on the treatment grid. Align the number of units billed on the UB-04 with those in the service log.


DON and medical records personnel

  • Verify each resident’s need for Medicare skilled intervention by reviewing supporting clinical documentation that corresponds with the dates of service listed in the manual census log.
  • Verify that each (re)certification form has been completed and signed by the appropriate physician.
  • Verify that each physician order has been obtained and implemented.
  • Verify that each chart reflects appropriate charting guidelines. Confirm that charting has been completed at least once in every 24-hour period, relates to skilled service provided, and supports therapy.


Facility rehab director

  • Verify that physician orders include rehabilitation.
  • Verify that each evaluation notes the prior level of function.
  • Verify that clinical documentation contains a progress note establishing the need for continued skilled intervention.



  • Chair the triple-check meeting (detailed below), and ensure that the entire process is completed by appropriate staff each month before Medicare claims are submitted. Participation in the triple check will allow the administrator to monitor the effectiveness of key operational processes carried out by the facility’s ­interdisciplinary team (IDT) on an ongoing basis.

Triple-check meeting and audit tool

Each of the SNF’s triple-check participants should complete their respective duties prior to the Medicare triple-check meeting, which will be held monthly before the SNF bills for a given batch of services. In other words, the meeting is not an occasion for staff to complete their initial claim component(s). Instead, it’s a chance for IDT members to cross-check the work of their colleagues by verifying the accuracy of claim items that others have completed, thereby ensuring each element has been studied by multiple sets of eyes.

The triple-check meeting will also serve as the platform for the SNF’s business office manager to document the completion of each integral item on a billing claim using the triple-check audit tool, an internal checklist-type document that will be included in every month-end closing report.

Using this audit tool, the manager will denote items verified as correct during the triple-check meeting with an "X." He or she will mark items identified as incorrect with an "O" and, in the remarks section of the document, record the steps the team will take to obtain the correct information. Items initially found to be incorrect but rectified during the meeting should still be marked with an "O" to better track any practice patterns that could lead to billing slipups and inform future training activities.

The business office manager will call for any claim found to have errors during the triple-check meeting to be put on hold until it is amended. Once staff have made necessary revisions, the manager will indicate these correction(s) and the corresponding date(s) in the remarks section of the audit tool. He or she will then contact a corporate entity to review the changes and ultimately grant approval to submit the claim. – Billing Alert for Long-Term Care

Compliance Is Not Complicated

To be sure your providers and employees are following all rules and regulations to keep your medical practice compliant, you should create a compliance program. The Office of Inspector General lists seven core components for an effective compliance program. Implement standards through written policies and procedures Providers and employees need written policies or procedures to […]
AAPC Knowledge Center

Briefings on Coding Compliance Strategies, September 2016

CMS’ 2017 IPPS final rule released

CMS released the fiscal year (FY) 2017 IPPS final rule August 2, and ICD-10-CM/PCS code changes and the addition of the Medicare Outpatient Observation Notice (MOON) both had starring roles. CMS also made changes to several quality initiatives and reversed the agency’s 0.2% payment reduction instituted along with the 2-midnight rule first implemented in the FY 2014 rule.

"Most coders have been hearing about the magnitudes of new codes being added to the ICD-10-CM and ICD-10-PCS code sets, and the final rule does not disappoint," says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, director of HIM and coding for HCPro, a division of BLR, in Middleton, Massachusetts.


ICD-10-CM and ICD-10-PCS updates

The final rule includes tables with nearly 2,600 lines of new ICD-10-CM codes and 14,000 lines of ICD-10-PCS codes on the associated Excel spreadsheets, some of which were not mentioned in the proposed rule, says McCall.

"Even with the thousands of additions to the ICD-10-CM code set, I think many will find that the additions look scarier than they actually are," says McCall. "For example, adding laterality (right, left, bilateral, unspecified) to conditions like diabetes mellitus retinopathy codes (categories E08?E11 and E13) equated to over 250 ‘new’ codes, but in reality, they are just added specificity that equate them to the detail in other eye disorder codes."

The eye disorders (Chapter 7, categories H00?H59) overall have a significant number of additions by way of further specificity like new stages or presence of symptoms?creating over 300 codes in that category, says McCall.

CMS has also introduced nearly 4,000 new codes for ICD-10-PCS in the final rule. But, McCall says, similar to the ICD-10-CM additions, some of the new ICD-10-PCS codes aren’t new procedures, but simply increases in specificity for one or more characters, which may result in hundreds of new codes.

"An example is the added distinction by subdividing the body part option of the thoracic aorta into the ascending/arch and descending portions," says McCall. "Therefore, any PCS table that included an option for the thoracic aorta now includes different body part values for ascending/arch thoracic aorta and descending thoracic aorta. These can create hundreds of codes once you provide all approach options, all device options, and all qualifier options for the associated ICD-10-PCS tables."

One of the more significant coding changes CMS has made, says McCall, is recognizing hundreds of procedures that were illogically considered surgical in ICD-10-PCS for FY 2016 but will be reclassified as nonsurgical in FY 2017. The intent of the transition from ICD-9-CM Volume 3 to ICD-10-PCS was for procedures to remain in the same (or similar) MS-DRGs that they occupied prior to ICD-10 implementation. However, not all codes were successfully reclassified. The 2017 IPPS final rule addresses some of these instances, including percutaneous drainage procedures such as paracentesis, as well as procedures like esophageal banding and arterial catheterization. Tables 6P.4a?6P.4k include all the procedures that will be reassigned as nonsurgical for FY 2017, says McCall.

"The reason for the assignment errors were mapping errors from ICD-9-CM Volume 3 to ICD-10-PCS. For example, the mapping for paracentesis (whether it was diagnostic or therapeutic) should have been to ICD-9-CM Volume 3 procedure code 54.91, but for some reason a diagnostic paracentesis was mapped to 54.29 (other diagnostic procedures on abdominal region)," says McCall.

CMS responded in the final rule to this mapping issue by saying:

We agree with the commenters that diagnostic drainage of the peritoneal cavity is more accurately replicated with ICD-9-CM procedure code 54.91 (percutaneous abdominal drainage) for reporting diagnostic paracentesis procedures and it is designated as a non-O.R. procedure. Therefore, we agree that the designation of ICD-10-PCS procedure code 0W9G3ZX (drainage of peritoneal cavity, percutaneous approach, diagnostic) should also be changed from O.R. to non-O.R.


The MOON form

In addition to creating new diagnosis and procedure codes, CMS also created the MOON as part of the Notice of Observation Treatment and Implication for Care Eligibility Act.

The MOON is a CMS-developed standardized notice hospitals are required to give to Medicare patients. These patients must be receiving observation services as an outpatient for more than 24 hours, and the MOON must be given no later than 36 hours after observation services are initiated. Hospitals must give a verbal explanation of the MOON to patients and obtain a signature to acknowledge receipt and understanding of the notice.


Payment adjustments

CMS also indicated that payment rates will increase by 0.95% in FY 2017 compared to FY 2016 for hospitals participating in the Inpatient Quality Reporting (IQR) Program and EHR meaningful use, according to the rule.

"This also reflects a 1.5 percentage point reduction for documentation and coding required by the American Taxpayer Relief Act of 2012 and an increase of approximately 0.8 percentage points to remove the adjustment to offset the estimated costs of the two-midnight policy and address its effects in FYs 2014, 2015, and 2016," said CMS.

In addition, CMS created two adjustments to reverse the effects of the 0.2% cut it instituted along with the 2-midnight rule, which has been the source of an ­ongoing legal challenge by the American Hospital Association and other parties. More on this story can be found here:

CMS made a permanent adjustment of approximately 0.2% to remove the cut for FYs 2017 and onward, and a temporary adjustment of 0.8% to address the retroactive impacts of this cut for FYs 2014, 2015, and 2016.


Quality program updates

CMS finalized five changes to the Hospital-Acquired Condition Reduction Program in this rule, as well as updates to the IQR Program, changes to the Hospital Readmissions Reduction Program, and updates to the Hospital Value-Based Purchasing Program.

Listening to commenter feedback, CMS reduced requirements for reporting electronic clinical quality measures (eCQM) as part of the IQR Program. Originally, CMS proposed requiring hospitals to submit data on all 15 eCQMs, but finalized a policy requiring hospitals to report four quarters of data on an annual basis for eight of the available eCQMs.

The entirety of the final rule is available in PDF format on the Federal Register, and it is expected to be officially published Monday, August 22. CMS says the rule applies to approximately 3,330 acute care hospitals and approximately 430 long-term care hospitals, and it will affect discharges occurring on or after October 1, 2016.

The final rule can be downloaded here:

The related CMS fact sheet can be viewed here:


2017 IPPS final rule and claims-based measures

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

The fiscal year (FY) 2017 IPPS final rule was released August 2 and will be published in the Federal Register August 22. The majority of the finalized updates are consistent with those outlined in the proposed rule, but with a few refinements to applicable time periods. The final rule expands and refines the number of claims-based ­outcomes linked to payment under these programs.

Let’s review a few of the key changes to support your CDI program’s strategic focus for the coming year.


Risk-standardized readmission rates

Risk-standardized readmission performance for the coronary artery bypass graft (CABG) cohort will be linked to reimbursement in FY 2017. The applicable time period for discharges used to assess performance in FY 2017 has passed, but today’s discharges will impact performance in FY 2018.

This is a great example of why it’s important to focus on new measures adopted in this year’s rule for future program years. CMS utilizes a two- to three-year historical window of data for claims-based measures, so today’s performance impacts us financially two to three years in the future.


Risk-adjusted PSI 90 composite

The current Patient Safety Indicator (PSI) 90 measure will continue to be utilized in the Hospital-Acquired Condition Reduction Program (HACRP) and Hospital Value-Based Purchasing Program (HVBP) through FY 2018. At that time:

  • The HACRP will adopt the modified PSI 90 composite in FY 2018
  • The HVBP will discontinue future use of the PSI 90 measure in the FY 2019 rulemaking?CMS notes that the HVBP intends to adopt the modified PSI 90 composite in future rulemaking


The modified PSI 90 composite, also called the Patient Safety and Adverse Events Composite, was finalized as proposed. A review of key modifications follows:

  • PSIs in the composite have been revised; one PSI was deleted (PSI 7?CLABSI) and three new PSIs were added, providing a total of 10 PSIs in the modified composite
  • The final rule notes that PSIs 12 and 15 have had specification revisions
  • PSI weighting in the composite has been refined to incorporate the impact of both volume and harm


Applicable time periods for the measure were shortened as proposed, although date ranges were revised as noted below in italicized font:

  • HACRP:
    • FY 2018: July 1, 2014?September 30, 2015 (15 months)
    • FY 2019: October 1, 2015?June 30, 2017 (21 months)
  • HVBP:
    • FY 2018: Same as HACRP above (for the performance period; the baseline period will not be revised)


Performance scoring for the HACRP will adopt Winsorized z-scores instead of deciles.

  • The z-score method uses a continuous measure score rather than forcing measure results into deciles.
  • Z-scores represent a hospital’s distance from the national mean for a measure in units of standard deviations. A negative z-score reflects values below the national mean, and thus indicates strong performance.
  • To form the total hospital-acquired condition (HAC) score, the z-scores will be used as hospitals’ measure scores. The current scoring approach will then kick in.
    • The domains will be scored as follows:
    • The domain scores will then be multiplied by the domain weight
    • The weighted domain scores will be added together for the total HAC score
    • Hospitals in the top (worst) quartile would be subject to the payment penalty


Risk-standardized mortality measures

Risk-adjusted CABG mortality performance will impact financial reimbursement under the HVBP effective with the FY 2022 program. The applicable time periods that will be used to assess performance at that time follow:

  • Baseline period: July 1, 2012?June 30, 2015
  • Performance period: July 1, 2017?June 30, 2020


The pneumonia cohort will expand to include patients with a principal diagnosis of aspiration pneumonia and/or patients with a principal diagnosis of sepsis and a secondary present-on-admission diagnosis of pneumonia:

  • This aligns the cohort definition with that for the pneumonia readmission measure adopted with the FY 2021 program year.
  • Applicable timelines will be shortened from the usual three years of data to expedite HVBP adoption. The applicable time period for the cohort follows; italicized font indicates refinements to the dates in the final rule:
    • FY 2021:
    • FY 2022:


Cost measures

The previously adopted HVBP payment measure for pneumonia (hospital-level, risk-standardized payment associated with a 30-day episode of care for pneumonia) will expand the pneumonia cohort.

The expanded cohort will be consistent with the cohort definition used for the risk-adjusted readmission measure in the Hospital Readmissions Reduction Program (HRRP) and the risk-adjusted mortality measure used in the HVBP:

  • The expanded cohort is anticipated to shift 9.3% of hospitals from the "average payment" category to the "greater than average payment" category

Two new payment measures will be added to the efficiency and cost reduction domain in the HVBP beginning FY 2021:

  • Hospital-level, risk-standardized payment associated with a 30-day episode of care for acute myocardial infarction
  • Hospital-level, risk-standardized payment associated with a 30-day episode of care for heart failure


These payment measures are intended to be paired with the 30-day mortality measures, thereby directly linking payment to quality by the alignment of comparable populations and risk adjustment methodologies to facilitate the assessment of efficiency and value of care:

  • The applicable time periods for the measures are as follows:
    • Baseline period: July 1, 2012?June 30, 2015
    • Performance period: July 1, 2017?June 30, 2019
  • The risk adjustment methodologies used for these measures are similar to those used for risk-adjusted mortality


Performance for these new measures will be scored using the methodology for the Medicare spending per beneficiary measure.



Effective October 1, 2017, performance for cost and quality measures in the HRRP, HVBP, and HACRP will impact up to 6% of your hospital’s inpatient acute Medicare fee-for-service reimbursement.

So, where to begin? First, become familiar with the measure specifications and risk adjustment methodologies, in addition to existing CMS provided reports on historical performance, to gain insights into your organization’s clinical documentation and coding vulnerabilities.

Measure specifications can be found at:

The final rule is available here:


Editor’s note: Newell is the director of CDI quality initiatives for Enjoin. She has extensive operational and consulting expertise in coding and clinical documentation improvement, performance improvement, case management, and health information management. You can reach Newell at [email protected] Opinions expressed are that of the author and do not represent HCPro or ACDIS.


Correctly documenting and coding altered mental status and encephalopathy


by James S. Kennedy, MD, CCS, CDIP


Last month, I wrote about the role of coding and CDI compliance in ensuring the clinical validity of submitted ICD-10-CM/PCS codes, which impact payment, outcomes measurement (e.g., complications, mortality, and readmissions), and patient safety.

Emphasizing that ICD-10 code assignment can no longer rely solely upon the words documented by a treating provider, a team effort involving compliance, coders, CDI, and physicians defining clinical terminology and managing the application of code conventions, guidelines, and official advice is crucial.

While a good lawyer knows the law, a better lawyer knows the law, the judge, and the jury. We in coding compliance must know not only the code assignment process, but also the accountability agents and attorneys who delight in finding what they perceive to be our mistakes.

In our defense, when we can state our case using the most up-to-date clinical definitions for the circumstances described by a treating provider and rigorously apply coding and CDI principles, we are more likely to prevail when publically accused of upcoding, abuse, or fraud.

On July 27, I was interviewed by the director of ­ACDIS, Brian Murphy, regarding the documentation and coding of encephalopathy, which has highlighted the tremendous confusion in the compliant definition, documentation, and coding of altered mental status and its underlying causes. This interview and its accompanying slides are available at

To discuss this topic, let’s review a little history first. The documentation and coding of encephalopathy wasn’t much of an issue until around 2007, when CMS designated the various encephalopathies (e.g., metabolic, toxic) as MCCs when they weren’t even CCs in the older CMS-DRG system.

Unlike unspecified heart failure?which is not a CC or MCC unless the physician states that it is systolic (HFrEF) or diastolic (HFpEF)?CMS allows unspecified or acute encephalopathy (ICD-10-CM code G93.40) to be an MCC while some of its descriptors (e.g., anoxic encephalopathy) are just a CC or nothing at all (e.g., G94, encephalopathy in diseases classified elsewhere).

When challenged as to why encephalopathy with (e.g., toxic, hepatic, metabolic, or NEC) or without an adjective should remain a MCC, CMS stated in its fiscal year (FY) 2012 IPPS rule that "its clinical advisers recommended that these encephalopathy codes remain at an MCC level because these patients with encephalopathy typically utilize significant resources and are at a higher severity level." Readers can view this quote in the Federal Register on pp. 51544 and 51545 at

Consequently, several hospitals and CDI consultants continue to advocate documentation and coding of the term "encephalopathy" alone in the presence of any altered mental status in order to obtain a MCC in MS-DRGs or a severity of illness of 3 in APR-DRGs. This is a practice that I believe is sure to be challenged, and one that requires thoughtful inquiry to ensure the validity of this or an alternative strategy.


Strategies for accuracy

Let’s now outline how to structure a diagnosis or condition for the purpose of ensuring completeness and precision in its ICD-10-CM coding. Every condition has five components that must be documented and linked to each other to fully describe that condition for coding purposes. Using the mnemonic MUSIC, and applied to an altered mental status, these are:

  • Manifestations?These could be delirium, psychosis, dementia, amnestic disorder, stupor, coma, unconsciousness, chronic vegetative state, and others, not just altered mental status or altered level of consciousness. Many of these are Chapter 18 symptoms, which cannot be a principal diagnosis if attributed to their underlying causes.
    • Note: Unresponsive doesn’t have a code; thus, an alternative term must be used.
    • Note: ICD-10-CM has code first requirements for the underlying cause of dementia (F01, F02), amnestic disorders (F04), delirium (F05), or other mental or personality disorders (F06, F07) due to a known physiological disorder, which means that if they were not documented or linked to the specified alteration of mental status or consciousness, they should be queried for. See the next section.
  • Underlying causes?These may include various structural brain diseases (e.g., strokes, cerebral neoplasms, cerebral edema, traumatic brain injury), neurodegenerative disorders (e.g., Alzheimer’s, Lewy body dementia, normal pressure hydrocephalus), or the various encephalopathies (e.g., toxic, metabolic, anoxic).
  • Severity or specificity?This includes whether any brain disease due to injury or medications is in the active treatment phase (initial encounter), healing phase (subsequent encounter), or has long-standing sequelae. If the doctor only documents "encephalopathy," we should query him or her as to its specific nature or underlying cause.
    • Note: The Glasgow Coma Scale measures severity; ICD-10-CM will add the National Institutes of Health Stroke Scale starting October 1, 2016. Note that both of these may be coded from non-provider documentation according to the 2017 ICD-10-CM Official Guidelines released in ­August 2016; thus, please encourage the nursing staff to capture these whenever possible.
    • Note: We may see codes for the severity of hepatic encephalopathy using the West-Haven classification (0, 1, 2, 3, or 4) in FY 2018; thus, consider discussing this with your gastroenterologists or hepatologists.
  • Instigating or precipitating cause?This is another condition that provoked the underlying cause or made it worse, such as a drug overdose causing a toxic encephalopathy, a cerebral embolus from atrial fibrillation causing a stroke, or a change in circumstances inciting behavioral changes with neurodegenerative disorders. Elder or child abuse should always be considered as well.
  • Consequences?These include seizures that may be the direct effect of a metabolic encephalopathy due to hyponatremia, a fracture that occurred during a drug-induced delirium or psychosis, or malnutrition due to poor oral intake in a patient with end-stage Alzheimer’s disease.


The definitions of the various altered mental states or levels of consciousness can be found in credible psychiatry (e.g., DSM-V) or neurological literature (e.g., Adams and Victor’s Principles of Neurology); thus, when the term "altered mental status" alone is documented, the physician should be queried for the exact nature of the altered mental state (e.g., delirium, amnestic syndrome, dementia). Please ask your coding or CDI physician champion for additional information on these definitions.


Focusing on encephalopathy

While there are many causes of altered mental status, let’s focus on encephalopathy.

The Greek etymology of the word "encephalopathy" means "disease of the brain," much like how the word "myopathy" means "disease of the muscle," "nephropathy" means "disease of the kidney," and "neuropathy" means "disease of the nerve." As such, one could construe any disease of the brain to be an encephalopathy, such as strokes, brain tumors, and the like. In fact, Dorland’s medical dictionary, available in 3M’s encoder, defines encephalopathy as "any degenerative disease of the brain." These definitions, in my opinion, are too broad.

I prefer the definition in Adams and Victor’s Principles of Neurology, 10th Edition, that defines encephalopathy as a global brain dysfunction that has an underlying cause distinct from any other named brain disease (e.g., Alzheimer’s). It could be a general medical condition (e.g., metabolic encephalopathy), a poisoning (e.g., toxic encephalopathy), chronic liver failure (e.g., hepatic encephalopathy), diffuse anoxia, or the like that results in the diffuse brain dysfunction. These, of course, would have to be defined, differentiated, and documented by the provider, emphasizing that they are separate, distinct, or overlying another underlying diffuse brain disease (e.g., Alzheimer’s).

Similarly, the National Institute of Neurological Disorders and Stroke states that encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure; access this at The hallmark of encephalopathy is an altered mental state.

There is a myriad of brain diseases, many of which have names (e.g., Alzheimer’s disease, Lewy body dementia, normal pressure hydrocephalus, and Jakob-Creutzfeldt disease) that are distinct disease entities whose labels describe the brain’s pathology and clinical manifestations. I personally believe that if the patient’s manifestations can be explained solely by a named brain disease, the term "encephalopathy" is integral to that named brain disease, given that the name is more specific than the term.

The ICD-10-CM Index to Diseases has similar examples, such as hepatic encephalopathy being classified as hepatic failure; in this circumstance, another code for encephalopathy would not be coded if the mental status abnormality is only due to hepatic failure.

Therefore, if encephalopathy is documented without linkage to any condition, a query is needed to determine its underlying cause. If it is due to a named disease not in the ICD-10-CM Index to Diseases under the key term encephalopathy, the underlying disease (e.g., UTI) is coded first, followed by G94 (other disorders of brain in diseases classified elsewhere), which is per the Excludes1 note for G93.4 (other and unspecified encephalopathy).

That’s not to say that a patient with a preexisting brain disease cannot have another superimposed process, which, if clinical indicators are present, should be defined, diagnosed, and documented by the physician. The ICD-10-CM Index to Diseases outlines many of these, such as toxic, metabolic, toxic-metabolic, hepatic, anoxic, and other types of encephalopathy. Definitions include:

  • Metabolic encephalopathy is a specified altered mental status due to a metabolic issue, such as hypercapnia (e.g., carbon dioxide narcosis), hyponatremia, pancreatitis, uremia, and the like.
  • Toxic encephalopathy is a diffuse brain dysfunction due to an adverse effect or a poisoning of a medication. Note that the ICD-10-CM Index to Diseases states that any encephalopathy due to a medication is coded to G92 (toxic encephalopathy), and that G92 has a code first instruction for any poisoning (T51?T64), which includes alcohol.
  • Toxic metabolic encephalopathies, which encompass delirium and the acute confusional state, are an acute condition of global cerebral dysfunction in the absence of primary structural brain disease. These are coded as G92 (toxic encephalopathy), unless the physician further specifies the toxic or metabolic issue. Queries regarding the definitions of metabolic or toxic etiologies are often required. While I don’t like this term, preferring to use the word "toxic" or "metabolic" alone, toxic-metabolic does exist in the clinical literature and coding nosologies. Learn more at
  • Hepatic encephalopathies are due to hepatic failure and are coded as such. In ICD-9-CM, all hepatic ­encephalopathies are MCCs; however, in ICD-10-CM, hepatic encephalopathy is only an MCC if associated with coma or if the hepatic failure is described as acute or subacute (less than six months in duration). Coding Clinic, Second Quarter 2016, emphasized that hepatic encephalopathy is not coded as coma unless documented by the provider as such, and if clinically valid (e.g., the patient is unconscious).
  • Hypoglycemic encephalopathy is listed as E16.2 (hypoglycemia, unspecified) in the ICD-10-CM Index; however, Coding Clinic, Third Quarter 2015, advised that encephalopathy due to hypoglycemia in a diabetic should be coded using E11.649 (Type 2 diabetes mellitus with hypoglycemia without coma) as the principal diagnosis, with G93.41 (metabolic encephalopathy) as an additional diagnosis. I have been told by Coding Clinic that the Editorial Advisory Board is revisiting this issue. Stay tuned for future Coding Clinic articles to see if they reverse this opinion (I think they should).


Let us at BCCS know how you’re faring with encephalopathy, especially as you write appeals.


Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at [email protected] Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. For any other questions, contact editor Amanda Tyler at [email protected] Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. – Briefings on Coding Compliance Strategies