AHA Coding Clinic® for ICD-9 - 2011 Issue 1; Ask the Editor
N-Methyl-D-Aspartate (NMDA) Receptor Antibody Encephalitis
The provider documented that a 27-year-old woman with NMDA (N-Methyl-D-aspartate) receptor antibody encephalitis was noted to have paranoid delusions and intermittent agitation. The patient had developed the NMDA receptor antibody encephalitis secondary to an ovarian teratoma. She was directly admitted for further workup and treatment of her presumed encephalitis. The provider’s final diagnostic statement listed, “NMDA receptor antibody encephalitis with psychotic disorder (paranoid delusions) most likely secondary to encephalitis.†What are the correct code assignments? ...
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Article Overview
This article discusses a clinical coding scenario involving NMDA receptor antibody encephalitis, associated psychotic symptoms, and an underlying ovarian teratoma. It is intended for coding professionals and others reviewing neurological and psychiatric diagnosis documentation. The article focuses on how the diagnosis is presented in the record and the broader coding context for assigning diagnoses in a complex inpatient case.
Why This Topic Matters
Cases like this can involve multiple documented conditions across neurology, psychiatry, and oncology-related findings, making accurate review of the primary diagnosis and associated conditions important for coding integrity and claims processing.
What You Will Learn
- How the clinical documentation frames autoimmune encephalitis in a complex case
- How associated psychiatric symptoms are presented in the coding scenario
- How an underlying tumor-related condition is part of the broader case context
- What type of diagnosis-coding question the article addresses
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Revenue cycle professionals
Codes Discussed
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