This page addresses follow-up questions and additional information pertinent to our webinar
Clearing the Brain Fog Around Coding Altered Mental Status.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: Should level of consciousness be coded when a patient has delirium, dementia, or psychosis?
A: In most cases, no. Codes representing level of consciousness are considered signs and symptoms associated with altered mental status and should not be assigned separately when the underlying condition – such as delirium, dementia, or psychosis – is already documented. There is, however, an important exception: R40.2A, Nontraumatic coma due to underlying condition, may be reported in addition to the documented underlying condition. In these cases, the underlying condition is sequenced first. Additionally, coma scale codes should only be used when coding traumatic brain injuries. They are not appropriate for non-traumatic or general altered mental status conditions.

Q: Anoxic encephalopathy sounds a lot like a stroke. Are they the same thing?
A: No, they are not the same. Although both conditions involve a disruption in oxygen reaching the brain, the mechanisms differ significantly. A stroke occurs when blood flow to a portion of the brain is interrupted or reduced. Because blood carries oxygen, this loss of circulation leads to decreased oxygen delivery and can result in neurological deficits. Anoxic encephalopathy, however, results from a complete lack of oxygen to the brain. This condition is not dependent on blood flow but instead reflects total oxygen deprivation. While they are distinct conditions, a stroke can lead to anoxic encephalopathy. Other potential causes include cardiac arrest, near-drowning, carbon monoxide poisoning, and choking.

Q: Can a patient have more than one kind of delirium; for example, dementia with delirium superimposed on delirium due to medications? If so, how should this be coded?
A: Yes. A provider may document delirium associated with more than one underlying condition, such as dementia and medication effects. In these situations, each documented type of delirium should be coded. Assigning all relevant delirium codes ensures the medical record reflects the full clinical picture and accurately captures the contributing conditions.

Q: How should toxic metabolic encephalopathy be coded when it occurs due to acute on chronic hepatic encephalopathy, now that a specific code exists for hepatic encephalopathy?
A: To accurately capture both conditions, assign the following codes:
• K76.82, Hepatic encephalopathy
• G92.8, Other toxic encephalopathy
These codes reflect the presence of both hepatic and toxic metabolic encephalopathy. It is important to note that earlier Coding Clinic guidance published in 1st Quarter 2021 and 1st Quarter 2022 predates the creation of the specific code K76.82. Before this code was introduced, hepatic encephalopathy was classified under the liver failure codes. The new code supersedes prior advice and allows for more precise coding.

Q: In case number 4 in the webinar, why is encephalitis listed as the principal diagnosis instead of the UTI?
A: In case 4, the patient was admitted for work-up of a new-onset of acute confusion with concern for delirium associated with Alzheimer’s dementia versus encephalopathy associated with an infection. His work-up revealed a UTI, which was ultimately found to be the cause of the patient’s encephalopathy. During the encounter, the patient also had agitation. The final diagnosis was metabolic encephalopathy superimposed on baseline dementia in the setting of a UTI. Coding Clinic, 2nd Quarter 2018, page 22 addresses encephalopathy due to UTI and states that the principal diagnosis is sequenced according to the circumstances of admission. Encephalopathy was sequenced first because it is the condition that “bought the bed.”

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