April 04, 2013 | | Comments 1
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Q&A: Coding ‘hepatic encephalopathy’ as a secondary condition

Have a question you'd like ACDIS experts to answer? E-mail mvarnavas@cdiassociation.com

Have a question you’d like ACDIS experts to answer? Email mvarnavas@cdiassociation.com

Q: What are the pros/cons of coding ‘hepatic encephalopathy’ as a secondary condition? For example, here is a clinical scenario that happened at our facility: A patient is admitted for pneumonia and the history and physical (H&P) states the patient has a ‘history of Hepatitis C with encephalopathy controlled with Lactulose, current grade 0 (zero).

In the opinion of the ACDIS Advisory Board members, is it compliant to code the Hepatitis C as with encephalopathy?

Donna Wilson: If a patient is admitted with viral hepatitis and also has hepatic encephalopathy, do not code hepatic encephalopathy (572.2) as a secondary diagnosis. Hepatic encephalopathy/coma is included in the code for the viral hepatitis (see AHA Coding Clinic for ICD-9-CM, 2007, 2nd Quarter, p. 6.)

Robert Gold:  My concern is that the name of the code is “with coma.”  When the patient is awake, alert, and not comatose, and therefore not being actively treated for coma, much less active delirium from hepatic encephalopathy (i.e., patient is stable on benchmark lactulose), do not code “with coma” just because the patient is under standard treatment—he doesn’t have it now.  This is a Recovery Auditor target.

Sylvia Hoffman: I agree with Donna. It would be inappropriate to code the encephalopathy. The Coding Clinic referenced also states if a patient is admitted with viral hepatitis and also hepatic encephalopathy, do not list hepatic encephalopathy as a secondary diagnosis. Hepatic encephalopathy/coma is included in the code for the viral hepatitis.

Donald Butler: Although I find the logic of the question very seductive, I’ve finally realized how to perhaps express why I have not been comfortable with this concept for a while. Coding for a chronic condition that is under control with treatment, etc., is one thing (i.e., end-stage renal disease [ESRD], congestive heart failure [CHF], etc.). The nuanced difference for me on this particular item is that coding the hepatic encephalopathy would be capturing the acute manifestation of the chronic problem (i.e., the underlying liver disease) that is not currently present but which the patient had previously. Encephalopathy is (per the National Institute of Neurological Disorders and Stroke) a global brain dysfunction, and the patient described in this scenario does not have that. One would not consider coding acute pulmonary edema or acute CHF in an ESRD patient is who stable and compliant with their treatment regime.

Secondly, although there is a non-essential modifier for hepatic encephalopathy (acute), it still suggests that the intent is for an acute problem. Furthermore, there is no index entry for chronic hepatic encephalopathy, and clinically I’m not sure such a condition exists. There are better ways to capture the treatment focused on the chronic liver condition, especially if the liver disease is advanced to the point of chronic failure.

Editor’s Note: This question was submitted for the ACDIS quarterly conference call of February 14, 2013, and  were answered by Donna Wilson, RHIA, CCS, CCDS, Robert Gold, MD, Sylvia Hoffman, RN, CCDS, CCDI, CDIP, and Donald Butler, RN, BSN, of the ACDIS advisory board.

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Melissa Varnavas About the Author: Melissa Varnavas, is the Associate Director of the Association of Clinical Documentation Improvement Specialists (ACDIS). ACDIS is a community in which CDI professionals share the latest tested tips, tools, and strategies to implement successful CDI programs and achieve professional growth. With more than 5,000 members, its mission is to bring CDI specialists together. To learn more about ACDIS, go to www.acdis.org or call HCPro customer service at 800-650-6787.

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