Letters to the Editor

Readers respond to articles on coding for encephalopathy and on assisted suicide.

Coding for encephalopathy

The article “Coding Corner: Encephalopathy “ (ACP Hospitalist, September 2010) makes two inaccurate points.

First, the definition given for encephalopathy—an acute, global impairment of cognition due to a reversible medical condition—is precisely the definition of delirium, and the terms are completely interchangeable when the onset is acute. Toxic-metabolic encephalopathy is delirium, for example.

Confusion arises because, by convention, a longer period of altered mental status is referred to as encephalopathy, as in hepatic encephalopathy, hypoxic ischemic encephalopathy, uremic encephalopathy, Wernicke's encephalopathy or Hashimoto's encephalopathy.

Second, delirium is described in the Diagnostic and Statistical Manual of Mental Disorders and is often treated by psychiatrists, but its cause is understood to be a medical, not a psychiatric, condition. The EEG is abnormal in delirium (encephalopathy) and normal in psychosis, depression and anxiety. Further information can be found in Trzepacz's 1996 article in Psychiatric Clinics of North America (volume 19, pages 429-48).

Of course, none of this touches on the best way to code for an acute change in mental status caused by a medical condition.

Peter J. Manos, PhD, MD

Editor's note: The following is Dr. Pinson's reply to Dr. Manos' letter.

I was very pleased to receive Dr. Manos' thoughtful and concerned letter about the clinical definition of delirium. It illustrates the complexity, confusion and frustration associated with trying to make the connection between our familiar clinical terminology and the strict requirements of documentation and coding rules and regulations.

I agree with Dr. Manos that we as physicians may consider acute encephalopathy and delirium as synonymous terms having the same definition and clinical implications. Unfortunately, the ICD-9-CM does not. If we only use the word “delirium” in our medical documentation, the codes assigned will simply report a nonspecific, general symptom of altered consciousness or a psychiatric mental disorder (under the category of psychoses) that undervalues the severity of illness associated with the acute encephalopathic state.

On the other hand, ICD-9-CM classifies “encephalopathy” as a specific neurologic diagnosis that will correctly identify a potentially serious or even life-threatening medical condition. A diagnostic statement in the medical record that includes “encephalopathy” when the appropriate criteria are met, as discussed in September's Coding Corner, solves this documentation/coding dilemma.

To ensure correct coding and reporting of our patients' problems as documented in our medical records, we must consider these regulatory facts of life. The objective of the Coding Corner column is to help hospitalists make the necessary connection between clinical medical record documentation and precise coding rules that accurately describe patients' severity of illness and the complexity of care provided.

Richard D. Pinson, FACP
Chattanooga, Tenn.

Assisted suicide

What is often lost in the debate about physician-assisted suicide (“Assisted suicide, “ ACP Hospitalist, September 2010) is the patient's right to his or her own life—and body. The rights to life and liberty encompass the right to end one's life and employ whatever assistance one may need from medical professionals. The only means of supporting a ban on physician-assisted suicide is to subscribe to a philosophy that reduces citizens to either vassals of the state or the property of a deity—both equally antithetical to American ideals. It is unfortunate that ACP does not support the three states that recognize this right.

Amesh A. Adalja, ACP Member
Butler, Pa.