Coding, Classification & Reimbursement

1.  Acute encephalopathy

Posted 4 days ago

I need help coding Acute encephalopathy secondary to seizure and/or alcohol intoxication. (listed as my final diagnosis)

Past medical history includes:
Alcoholism (not in remission) Alcoholic cirrhosis
Seizure disorder

The patient presented after having a seizure at home, intoxicated.  He was given IV Ativan in the ER bolused with Keppra and then placed on routine home medications for seizure disorder..  Alcohol level on admission was 27.  He was kept inpatient for 2 days for reorientation and treat the encephalopathy.

It is noted in the ER record that he had been taking his seizure medications as ordered, but had been drinking heavily.  On the history it was originally stated that the seizure was due to the intoxication.

Metabolic encephalopathy was given as a diagnosis in her progress notes.

I am unclear as to how to code this scenario. I would be interested in hearing someone else's opinion?

Thanks,

Charlene Marble, CCS



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CHARLENE MARBLE
Inpatient coder
King's Daughters Hospital
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2.  RE: Acute encephalopathy

Posted 2 days ago
Dear Charlene,

I would use code G31.2 for the alcoholic encephalopathy and the code the seizure due to alcoholic intoxication separately. I would also advise that before you do code anything that you double check the documentation to make sure that you understand and are clear about the presentation of the diagnoses.

Jodi Miller, RHIT, CCS

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Jodi Miller, RHIT, CCS
Outpatient Coder/Abstractor
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