He denies chest pain, shortness of breath, nausea/vomiting/diarrhea, penile discharge, hematuria, blood in stool, or IV drug use. His family states he has a history of alcohol abuse. The pain is described as sudden onset, sharp, constant, 9/10, non-radiating, associated with dysuria, urgency, fever, though nothing improves or worsens his pain. Knox sees a 52-year-old male with past history of hypertension, brought in by EMS for 2-days of fever and suprapubic pain. He and Cynthia Tang, RHIA, CCS, principals at Pinson and Tang, LLC.Dr. Pinson is the co-author of the CDI Pocket Guide and the Outpatient CDI Pocket Guide: Focusing on HCCs. Whenever “metabolic encephalopathy” is documented, code G93.41, Metabolic encephalopathy, should be assigned.Įditor’s note: Richard Pinson, MD, FACP, CCS, answered this question.

In the case of a UTI, it would be metabolic encephalopathy even in the absence of fever or other specific findings since many susceptible patients, especially the elderly, experience encephalopathy with any infection.

It is always appropriate to query for the specific type of encephalopathy whenever it is caused by any of these conditions.

24-25 advises coders to assign G93.49, Other encephalopathy, for documentation of “encephalopathy due to urinary tract infection (UTI).” Can code G93.41, Metabolic encephalopathy, be assigned for provider documentation of “metabolic encephalopathy due to UTI?” For cases involving documentation of unspecified encephalopathy (CC) due to a UTI, is it appropriate to query for further specificity of the type of encephalopathy, such as metabolic encephalopathy (MCC)?Ī: Metabolic encephalopathy is caused by such things as fever, dehydration, electrolyte imbalance, hypoglycemia, hypoxemia, any infection, and organ failure. Q: We’re struggling with one particular aspect of encephalopathy.

Icd 10 code for uti