Chart Check Up
Leveraging clinical perspectives for the middle revenue cycle – insights that drive impact. Offering support to keep current on clinical knowledge, coding updates, and industry trends.
Chart Check Up
Distinguishing Delirium in the Encephalopathy Enigma
We walk through how to distinguish delirium from encephalopathy using DSM-5 criteria, CAM tools, and clear coding pathways, and we show where they overlap and why it matters. We share practical examples, denial risks, and how nurses’ notes fuel better queries and outcomes.
• DSM-5 features and CAM thresholds for delirium
• F-code specificity for intoxication and withdrawal states
• G-code encephalopathy and system-specific hepatic coding
• Overlap of causes and resolution with treatment
• Differentiating waxing and waning vs acute course
• CC/MCC, Elixhauser, PSI 11 and denial risk
• Using nurses’ notes to build strong queries
• Key resources for fast, reliable criteria checks
At Acuity, we're transforming healthcare reimbursement with a provider-driven, innovative approach. If you have any questions or would like to offer a topic to discuss, please email info at acuityhealthcare.com.
Welcome to Chart Checkup, Clinical Perspectives for the Middle Revenue Cycle. This podcast delivers insights that drive impact in healthcare information management. Stay current on clinical knowledge, coding updates, and industry trends through expert interviews and conversations with Acuity's own physician, CDI, and coding leaders. Well, today on the podcast, we're very lucky to have a guest from Acuity, Senior Director of CDI, Verona Loldholz, is joining us to discuss a clinical topic today. Verona, how are you?
SPEAKER_01:I am good. How are you?
SPEAKER_00:Oh, I'm doing all right. I'm excited to have you here, and that we've uh elected to talk about delirium. But uh right off the bat, I was hoping that um you'd give our listeners a quick breakdown of your expertise and your work history.
SPEAKER_01:Sure. I am a C uh CCDS certified CDI who also has my coding certification of a CCS, and I came from a diverse clinical background, including the medical laboratory, for many years, and I am a chiropractor who had a chiropractic office for several years. And I found my way to CDI and have been happy here ever since, working in CDI since 2012.
SPEAKER_00:I love it. I appreciate it. And so I get getting started, we'll talk a little bit about delirium, but then I feel like uh just getting started with sort of uh a basic understanding of how we'll differentiate delirium from encephalopathy and sort of the complex coding tasks that are uh associated with trying to ferret that out. Do you have any thoughts on that?
SPEAKER_01:Sure. The two go hand in hand. And so delirium and encephalopathy are very aligned with one another and yet have differentiations. So in order to really determine what codes need to be utilized or if you need to query, you need to have a basic understanding of the two diagnoses.
SPEAKER_00:Um well, how would you break down delirium for uh for uh for us as a diagnosis?
SPEAKER_01:Well, delirium is considered a psychiatric diagnosis, and it even though it's described as an alteration to the patient's mental status, just as encephalopathy is, there are five key features for delirium that are defined in the DSM fifth edition, and that includes disturbance and attention, which is described as reduced ability to direct, focus, sustain, and shift attention and awareness. The disturbance develops over a short period of time, usually hours to days, represents a change from baseline and tends to fluctuate during the course of the day. The third key is an additional disturbance in cognition, such as memory deficit, disorientation, language, visio-spatial ability, or perception is present. Fourth is the disturbances are not better explained by another pre-existing, evolving, or established neurocognitive disorder and do not occur in the context of a severely reduced level of arousa that would meet a coma definition. And lastly, there is evidence from the history, physical exam, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal or a medication side effect. So these five points are used to identify delirium using the CAM method, which is the confusion assessment method. There's also the CAM ICU method for patients that may be mechanically ventilated. To meet that diagnosis or the criteria for delirium, there must be either one of two of two of presence of acute onset and fluctuating discourse or inattention. And then either, in addition to one of those two, disorganized thinking or an altered level of consciousness. So those are required. That's a very finite group of findings to determine that the patient has delirium. And that is different than what we see with encephalopathy. When it comes to coding the delirium, if there's no further specificity, the diagnosis just goes to an R code, which is a sign or symptom code, R4 1.0 disorientation unspecified. When we do have further delineation as to the cause or the determination of the delirium, then you end up with an F code, which is in the grouping of the mental, behavioral, and neurodevelopmental disorder category. And these codes for delirium are associated, are associated with substance abuse. And when they are, it's specific to the substance and whether or not withdrawal is present. So there's a thorough review needed of all of those different codes to determine the appropriate one in these cases.
SPEAKER_00:To be honest, I was really blown away. I made some notes to talk about uh whether it was intoxication or withdrawal induced for induction for it, that it was really interesting to see that the coding is capturing both sides of that sort of um of situation. But uh I was surprised by that.
SPEAKER_01:Well, sure. For example, um the code F10.231 is alcohol dependence with withdrawal delirium. So there we have a combo code for the alcohol dependence. We have the specific finding of alcohol, and then that patient is experiencing withdrawal delirium. On the other hand, code F14.221 is cocaine dependence with intoxication delirium. So again, we have the specific finding of cocaine dependence, but in this case, it's intoxication, not withdrawal. So it gets down to a deep level of specificity.
SPEAKER_00:It really does. It's amazing.
SPEAKER_01:And then if we contrast that to encephalopathy, that's considered more of a clinical diagnosis, and it has a broad definition, such as just alteration in function and or structure of the brain. This is displayed as an alteration of mental status due to systemic factors. And this association with the brain ends up in the diagnosis code from the nervous system category, which are generally G codes, and the individual G codes are designated based on the underlying cause, but not to that same level of specificity. There, these are broad categories, including metabolic, toxic, or hepatic. And when the encephalopathy is identified to the specificity of hepatic, you would go to the system specific code rather than that G code. Can I give you a couple examples here?
SPEAKER_00:I would love it. Thank you.
SPEAKER_01:So G93.41 is metabolic encephalopathy. It's that vague. There are not additional characters that get us um a further specified diagnosis. Hepatic encephalopathy without coma goes to K76.82. So there we have we have encephalopathy, but with a different underlying cause, it takes us to it to a different um category. And both of these conditions can have underlying metabolic or drug and alcohol related causes. Both delirium and encephalopathy can have underlying metabolic or drug alcohol related causes. And both delirium and encephalopathy can resolve when the underlying cause is corrected. So, for example, we may have metabolic encephalopathy due to alterations in the system, including electrolyte or glucose imbalances. Liver failure may result in hepatic encephalopathy with symptoms that may include asterisks, and drug or alcohol ingestion or its effects may result in a toxic encephalopathy. Infection can cause encephalopathy, which is more common in the older adult. And at the same time, any of these conditions can also result in delirium, including some of the same symptoms, such as asterisks and liver failure. Encephalopathy itself may result in delirium. So you can see how these two conditions really overlap. And another feature that's common to both is that they can both be superimposed on dementia. So it's very important to determine what that patient's baseline is in order to determine what this new acute or subacute condition is resulting in. So the any change in the patient's status must be compared to their baseline in order to determine this. So with all of that, we just talked about all the ways that they're sub very similar. And let me touch a little bit on how they can be different. Because it's not uncommon for us to see that the providers are using both terms interchangeably, and that's totally understandable with the the traits that they both share. However, delirium is generally developing over hours to days and typically may persist for days to months. And delirium is more likely to fluctuate throughout the day. And in fact, sundowning is a behavioral deterioration that's seen in the evening hours, and that is typically more common in a patient that has the underlying dementia. Whereas an acute encephalopathy more typically has a very acute onset and is noted with gradual or quick resolution once that underlying cause is addressed. So that waxing and waning isn't as common to an acute encephalopathy. And it's careful evaluation is needed to confirm the proper diagnosis in these patients with altered mental status. Also notable is that several of these encephalopathies are considered MCCs. And if they sit on a case as a singular MCC, that may be prone to a denial. So queries in these cases can be beneficial to support that encephalopathy diagnosis and code. On the other hand, your F-category delirium codes are typically CCs, and the code F05 delirium, due to a known physiological condition, not only serves as a CC, it also serves as an impact to the Elixhauser comorbidity index and as well as several quality metrics, and additionally provides an exclusion for your PSI 11 postoperative respiratory failure. It's interesting to know that the subcategories listed for F05 include some very vague terms such as acute or subacute brain syndrome, acute or subacute confusional state, as long as it's not related to alcohol, acute or subacute infective psychosis, acute or subacute organic reaction, acute or subacute psychoorganic syndrome, delirium of a mixed etiology, delirium superposed on dementia. So that encompasses those both conditions in that phraseology, and sundowning, that condition that I mentioned about the changes that occur at the end of the day. So these conditions both are supported by, or the coding of these conditions are both supported by multiple coding clinics. And you need to utilize all of the clues in the record, all of the documentation from the providers, as well as the coding clinics to assist in your decision making when you're reviewing these cases and comparing and contrasting these two analogous conditions.
SPEAKER_00:That's a really amazing breakdown. I really appreciate it. That's a very complex talk uh topic to tackle. Excuse me, sorry, it's a very complex topic to tackle there. And uh I think that you've really highlighted both, as you said, some of the similarities and some of the differences. It's uh a really uh interesting space.
SPEAKER_01:I totally agree. And and it it could be a day-long topic on on either of them because they are very involved. And yet most of us in the coding and CDI world have only a fraction of that time to make a determination of what code to apply or whether or not we should place a query for further clarification.
SPEAKER_00:Absolutely. Yeah. I was speaking with uh a neurologist we have on staff here, uh, who um gave me some insight into uh looking for that sort of comparison of delirium versus other conditions that and exactly as you had, I think you had even sped the specific term she used, which was waxing and waning, of the condition for delirium being such a key part. But she also had brought up looking into uh the nurse's notes um for more clues. Do you have any uh thoughts on like where the best uh place to gain a better insight would be in the medical record?
SPEAKER_01:The nurses' notes are are generally a wealth of information because they're documenting what they observed, what they handled during their shift. And those are often clues that we use for query when we need to request that the provider give us an accurate diagnosis here. So it's not at all uncommon to see the provider acknowledge that this chain, this patient has a change in mental status and not diving any further. So then we can review the nurse's notes to determine did this person need to have more intervention? Was there a request made to move the patient to a room closer to the station for closer observation? Those types of details aren't often found in the provider's documentation, but we can use those as indicators to ask the provider for clarification on their statement and their generic statement of altered mental status.
SPEAKER_00:That's a great insight. I like that. I appreciate it.
SPEAKER_01:These topics have a lot of similarities, and yet there are differences. And there's some great resources out there. For example, UpToDate has a heading called Diagnosis of Delirium and Confusional States that offers a lot of good information. And even the Actus Pocket Resource Online talks a lot about the differences between encephalopathy and delirium. So utilizing the resources does help give further clarity to these conditions.
SPEAKER_00:Well, I really appreciate you joining us here on the podcast today, Verona. Thank you for your time and your expertise. It was wonderful to both speak with you and to hear about uh the complexities of delirium.
SPEAKER_01:Thank you for having me.
SPEAKER_00:At Acuity, we're transforming healthcare reimbursement with a provider-driven, innovative approach. We share valuable clinical and coding insights and current best practices to improve financial outcomes across health systems. If you have any questions or would like to offer a topic to discuss, please email info at acuityhealthcare.com. Opinions expressed in this production are those of the host or guests and do not represent official stances of acuity. The suggestions, advice, and guidance provided by the individuals featured in this podcast are not intended to replace any medical advice, consultation, or treatment you may receive from your healthcare provider.
