Cracking the Code

Coding Encephalopathy with Cerebrovascular Accident

Encephalopathy is a general term for brain disease that alters brain function or structure. There are multiple causes of encephalopathy, such as infection/viral, anoxia, brain trauma, cerebrovascular accident (CVA), metabolic disorders, or toxic chemicals (just to name a few). When a provider documents encephalopathy due to CVA, it is appropriate to report the encephalopathy as an additional diagnosis. Per AHA guidance, it is NOT considered to be inherent to the CVA. Coders should assign two diagnoses for both conditions to fully and completely capture the picture for that patient’s encounter. If a provider documents a specific type of encephalopathy, then coders should report that specific diagnosis code. If a provider does not document a specific type, then it is appropriate to report G93.49, other encephalopathy.

Q: A 70-year-old male presents to the ED with complaints of weakness, altered mental status, and slurred speech. Patient is admitted into inpatient status. Upon discharge, the provider documents encephalopathy due to CVA as their final diagnosis.
A: I63.9, cerebral infarction, unspecified G93.49, other encephalopathy,
Reference: AHA Coding Clinic Second Quarter 2018, pages 24-25
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