Clinical Documentation Improvement Series #3, Is it Delirium or Encephalopathy?

The use of the terms delirium or encephalopathy are often not used when documenting a patient's change in mental status. In the coding world, the term“change in mental status” is only recognized as a sign, not as a diagnosis. A diagnosis encephalopathy should be used when there is a toxic (exogenous), metabolic (endogenous) or anatomic abnormality leading to a brain dysfunction. It is preferable to use the term delirium when the provider refers to an acute change in mental condition linked to a psychological or psychiatric condition, such as mania or acute psychosis. Additionally, the term delirium should also used to describe changes in mental status related to substance withdrawal.

Marco A. Ramos MD, CCDS

In order to quote from this article please use the following:

Marco A. Ramos, “Clinical Documentation Improvement Series #3, Is it Delirium or Encephalopathy?,” SMO Blog (blog), August 10, 2018, https://steemit.com/health/@secondmedicalop/clinical-documentation-improvement-series-3-is-it-delirium-or-encephalopathy