AHA Coding Clinic® for ICD-9 - 1988 First Quarter
Metabolic Encephalopathy
Note: As of October 1, 2003 code 348.3 Encephalopathy, unspecified, has be expanded to the fifth digit level to include code 348.31 Metabolic encephalopathy. Metabolic encephalopathy refers to an altered state of consciousness, usually denoting delirium. The delirium is either hypoactive or hyperactive in form, is transient in nature, and is essentially a reversible dysfunction in cerebral metabolism. The term "acute confusional state" may be used by some physicians to describe metabolic encephalopathy. The code assignments in the Alphabetic Index of ICD-9-CM for delirium and acute confusional state are compatible. In most instances, the associated condition or...
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Article Overview
This premium article explains how metabolic encephalopathy is discussed in the ICD-9-CM context and how it relates to delirium and related diagnostic terminology. It is intended for coding professionals who need to understand the topic’s placement in the classification system, the associated condition concepts, and the documentation context referenced in the article. The article also notes code title changes, category relationships, and the general circumstances in which linked conditions are considered.
Why This Topic Matters
Accurate identification of metabolic encephalopathy in documentation can affect diagnosis classification and the way related conditions are represented in the medical record. The article helps coders and CDI staff understand the surrounding ICD-9-CM references and terminology updates tied to this topic.
Article Sections
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October 1, 2003 update
Introduces an ICD-9-CM update related to encephalopathy terminology and classification structure.
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Definition and related terminology
Describes the clinical concept of metabolic encephalopathy and how it may be referenced in physician documentation.
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Associated conditions and causes
Summarizes the broad categories of conditions that may be documented alongside the topic in the medical record.
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Metabolic encephalopathy (see Delirium) refers to any of the following conditions
Presents related delirium-focused classification references and associated ICD-9-CM terminology notes.
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Not listed under Delirium, but of importance for coding purposes are the following
Lists additional related documentation topics referenced for coding consideration outside the main delirium listing.
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Tabular List guidance and exclusions
Notes the importance of reviewing related Tabular List guidance and exclusion relationships for the surrounding category.
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Instructional note and diagnosis placement
Addresses the general documentation context for identifying associated conditions and the role of principal diagnosis assignment.
What You Will Learn
- How metabolic encephalopathy is framed within ICD-9-CM terminology
- How the article relates metabolic encephalopathy to delirium and acute confusional state language
- What kinds of associated conditions and documentation context are discussed
- Which related ICD-9-CM references and category notes are highlighted
- Why surrounding Tabular List guidance is relevant to this topic
- How the article describes diagnosis placement in the admission record context
Who Should Read This
- Medical coders
- Clinical documentation integrity professionals
- Coding auditors
- Health information management staff
Codes Discussed
Code Ranges Discussed
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