{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T12:48:29Z","timestamp":1770814109120,"version":"3.50.1"},"reference-count":52,"publisher":"American Health Information Management Association","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Adv Health Inf Sci Pract"],"published-print":{"date-parts":[[2025,8,12]]},"abstract":"<jats:p>Encephalopathy, a multifaceted condition marked by altered brain function, poses significant challenges in diagnosis, documentation, and coding within clinical settings. It occurs secondary to an underlying condition and requires specific diagnostic clarity to distinguish its types, such as hepatic, hypertensive, or metabolic encephalopathy, each presenting with unique clinical indicators. The lack of official coding guidelines for encephalopathy exacerbates these challenges, leading to frequent claim denials. Consistent and clear communication among healthcare providers, coders, and clinical documentation specialists is essential for validating diagnoses and accurately representing a patient\u2019s condition. Via a review of 26 articles and forums, the authors synthesize the complexities of encephalopathy diagnosis and documentation, exploring how varied etiologies impact coding accuracy and reimbursement. This report underscores the need for standardized documentation practices, accurate use of ICD-10-CM codes, and proper querying techniques to support coding and documentation integrity.<\/jats:p>","DOI":"10.63116\/vzze2856","type":"journal-article","created":{"date-parts":[[2025,8,12]],"date-time":"2025-08-12T19:27:32Z","timestamp":1755026852000},"source":"Crossref","is-referenced-by-count":0,"title":["Current Challenges in Encephalopathy Documentation and Coding"],"prefix":"10.63116","volume":"1","author":[{"given":"Jaime","family":"Sand","sequence":"first","affiliation":[{"name":"College of Health Sciences Boise State University https:\/\/dx.doi.org\/https:\/\/ror.org\/02e3zdp86"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alba","family":"Kuqi","sequence":"additional","affiliation":[{"name":"Department of Public Health, Georgia Southern University"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"52461","reference":[{"issue":"3","key":"ref-472280","series-title":"Clin Med","first-page":"e46","article-title":"Posterior reversible encephalopathy syndrome","volume":"20","author":"Jia","year":"2020","unstructured":"Jia\n              L.\n            \n            \n              Zhang\n              H.\n            \n           Posterior reversible encephalopathy syndrome. Clin Med. 2020;20(3)e46\n          10.7861\/clinmed.Let.20.3.1\n          32414741\n          PMC7354024"},{"key":"ref-472281","series-title":"Encephalopathy","author":"Cleveland Clinic","year":"2023","unstructured":"Cleveland Clinic\n          . Encephalopathy. 2023. Accessed April 1, 2024. https:\/\/my.clevelandclinic.org\/health\/diseases\/encephalopathy"},{"key":"ref-472282","series-title":"Do\u2019s and don\u2019ts of reporting encephalopathy","author":"Boy","year":"2021","unstructured":"Boy\n              K.\n            \n           Do\u2019s and don\u2019ts of reporting encephalopathy. August 16, 2021. Accessed January 9, 2024. https:\/\/hiacode.com\/blog\/education\/coding-tip-reporting-encephalopathy"},{"issue":"2","key":"ref-472283","series-title":"Cureus","first-page":"e22102","article-title":"Inpatient management of encephalopathy","volume":"14","author":"Reddy","year":"2022","unstructured":"Reddy\n              P.\n            \n            \n              Culpepper\n              K.\n            \n           Inpatient management of encephalopathy. Cureus. 2022;14(2)e22102\n          10.7759\/cureus.22102\n          35291547\n          PMC8917954"},{"key":"ref-472285","series-title":"Encephalopathy","author":"Boy","year":"2023","unstructured":"Boy\n              K.\n            \n           Encephalopathy. July 10, 2023.  Accessed April 1, 2024. https:\/\/hiacode.com\/blog\/education\/encephalopathy"},{"key":"ref-472286","series-title":"Taking the mystery out of encephalopathy","author":"Valdez","year":"2018","unstructured":"Valdez\n              D.\n            \n           Taking the mystery out of encephalopathy. 2018"},{"key":"ref-472287","series-title":"Denied!","author":"Johnson","year":"2024","unstructured":"Johnson\n              L. M.\n            \n           Denied!. January 22, 2024. Accessed April 23, 2024. https:\/\/icd10monitor.medlearn.com\/denied\/"},{"key":"ref-472289","series-title":"International Classification of Diseases, Tenth Revision, Clinical Modification","author":"National Center for Health Statistics (NCHS)","year":"2024","unstructured":"National Center for Health Statistics (NCHS)\n          . International Classification of Diseases, Tenth Revision, Clinical Modification. 2024"},{"key":"ref-472288","series-title":"Brain Behav Immun-Health","first-page":"100136","article-title":"Acute encephalopathy is associated with worse outcomes in COVID-19 patients","volume":"8","author":"Shah","year":"2020","unstructured":"Shah\n              V. A.\n            \n            \n              Nalleballe\n              K.\n            \n            \n              Zaghlouleh\n              M. E.\n            \n            \n              Onteddu\n              S.\n            \n           Acute encephalopathy is associated with worse outcomes in COVID-19 patients. Brain Behav Immun-Health. 2020;8:100136\n          10.1016\/j.bbih.2020.100136\n          32904923\n          PMC7462562"},{"key":"ref-472290","series-title":"Physicians advisor\u2019s corner: Clearing the confusion about encephalopathy","author":"Maguir","year":"2019","unstructured":"Maguir\n              A. B.\n            \n           Physicians advisor\u2019s corner: Clearing the confusion about encephalopathy. November 22, 2019. Accessed July 2, 2024.\n          https:\/\/www.premierhealth.com\/your-health\/articles\/premier-pulse\/physicians-advisor-s-corner-clearing-the-confusion-about-encephalopathy"},{"key":"ref-472291","series-title":"A CDI revolution unfolding","author":"Krauss","year":"2019","unstructured":"Krauss\n              G.\n            \n           A CDI revolution unfolding. March 18, 2019. Accessed April 23, 2024.\n          https:\/\/medlearn.com\/a-cdi-revolution-unfolding\/"},{"key":"ref-472292","series-title":"Denials management toolkit","author":"Edwards","year":"2023","unstructured":"Edwards\n              M. E.\n            \n            \n           Denials management toolkit.  2023. Accessed April 23, 2024.\n          https:\/\/bok.ahima.org\/topics\/coding-compliance-and-revenue-cycle\/denials-management-toolkit\/"},{"issue":"16","key":"ref-472293","series-title":"CDI Strategies","article-title":"ACDIS update: ACDIS poll reveals members\u2019 top 10 queried diagnoses","volume":"12","author":"Association of Clinical Documentation Integrity Specialists (ACDIS)","year":"2018","unstructured":"Association of Clinical Documentation Integrity Specialists (ACDIS)\n           ACDIS update: ACDIS poll reveals members\u2019 top 10 queried diagnoses. CDI Strategies. 2018;12(16"},{"issue":"55","key":"ref-472294","series-title":"CDI Strategies","article-title":"Q Encephalopathy due to UTI versus metabolic encephalopathy due to UTI","volume":"12","author":"Pinson","year":"2018","unstructured":"Pinson\n              R.\n            \n           Q Encephalopathy due to UTI versus metabolic encephalopathy due to UTI. CDI Strategies. 2018;12(55"},{"issue":"9","key":"ref-472284","series-title":"The Livanta Claims Review Advisor","article-title":"Higher-weighted diagnosis related groups (HWDRG) validation - Encephalopathy","volume":"1","author":"Livanta QIO","year":"2022","unstructured":"Livanta QIO\n           Higher-weighted diagnosis related groups (HWDRG) validation - Encephalopathy. The Livanta Claims Review Advisor. 2022;1(9"},{"key":"ref-472295","series-title":"CDI queries work best if the recipient is kept in mind","author":"Remer","year":"2024","unstructured":"Remer\n              E.\n            \n           CDI queries work best if the recipient is kept in mind. March 7, 2024. Accessed July 2, 2024.\n          https:\/\/medlearn.com\/cdi-queries-work-best-if-the-recipient-is-kept-in-mind\/"},{"issue":"181","key":"ref-472296","series-title":"CDI Blog","article-title":"From the forum: Denial proofing queries","volume":"11","author":"ACDIS","year":"2018","unstructured":"ACDIS\n           From the forum: Denial proofing queries. CDI Blog. 2018;11(181"},{"key":"ref-472297","series-title":"Practice brief: Clinical validation","author":"Carr","year":"2023","unstructured":"Carr\n              K. M.\n            \n            \n           Practice brief: Clinical validation. 2023. Accessed August 21, 2023.\n          https:\/\/www.ahima.org\/landing-pages\/clinical-validation-practice-brief\/"},{"key":"ref-472298","series-title":"ICD-10-CM official guidelines for coding and reporting","author":"CMS","year":"2024","unstructured":"CMS\n          . ICD-10-CM official guidelines for coding and reporting.; 2024."},{"issue":"4","key":"ref-472299","series-title":"Coding Clinic","article-title":"Encephalopathy associated with cerebrovascular accident","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2017","unstructured":"American Hospital Association (AHA)\n           Encephalopathy associated with cerebrovascular accident. Coding Clinic. 2017;Second Quarter(4"},{"issue":"8","key":"ref-472300","series-title":"Coding Clinic","article-title":"Static encephalopathy due to epilepsy","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2021","unstructured":"American Hospital Association (AHA) \n           Static encephalopathy due to epilepsy. Coding Clinic. 2021;Second Quarter(8"},{"issue":"3","key":"ref-472301","series-title":"Coding Clinic","article-title":"Hepatic encephalopathy","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2016","unstructured":"American Hospital Association (AHA) \n           Hepatic encephalopathy. Coding Clinic. 2016;Second Quarter(3"},{"issue":"3","key":"ref-472302","series-title":"Coding Clinic","article-title":"Encephalopathy due to diabetic hypoglycemia","volume":"Third Quarter","author":"American Hospital Association (AHA)","year":"2016","unstructured":"American Hospital Association (AHA) \n           Encephalopathy due to diabetic hypoglycemia. Coding Clinic. 2016;Third Quarter(3"},{"issue":"4","key":"ref-472303","series-title":"Coding Clinic","article-title":"Encephalopathy due to sepsis","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2017","unstructured":"American Hospital Association (AHA) \n           Encephalopathy due to sepsis. Coding Clinic. 2017;Second Quarter(4"},{"key":"ref-472304","series-title":"ICD-10-CM\/PCS MS-DRG v41.1 definitions manual","author":"Centers for Medicare and Medicaid Services (CMS)","year":"2024","unstructured":"Centers for Medicare and Medicaid Services (CMS)\n          . ICD-10-CM\/PCS MS-DRG v41.1 definitions manual. 2024. Accessed August 2, 2024.\n          https:\/\/www.cms.gov\/icd10m\/FY2024-version41.1-fullcode-cms\/fullcode_cms\/P0031.html"},{"issue":"39","key":"ref-472305","series-title":"CDI Strategies","article-title":"Q Denials for encephalopathy","volume":"12","author":"Frady","year":"2018","unstructured":"Frady\n              A.\n            \n           Q Denials for encephalopathy. CDI Strategies. 2018;12(39"},{"issue":"3","key":"ref-472280","series-title":"Clin Med","first-page":"e46","article-title":"Posterior reversible encephalopathy syndrome","volume":"20","author":"Jia","year":"2020","unstructured":"Jia\n              L.\n            \n            \n              Zhang\n              H.\n            \n           Posterior reversible encephalopathy syndrome. Clin Med. 2020;20(3)e46\n          10.7861\/clinmed.Let.20.3.1\n          32414741\n          PMC7354024"},{"key":"ref-472281","series-title":"Encephalopathy","author":"Cleveland Clinic","year":"2023","unstructured":"Cleveland Clinic\n          . Encephalopathy. 2023. Accessed April 1, 2024. https:\/\/my.clevelandclinic.org\/health\/diseases\/encephalopathy"},{"key":"ref-472282","series-title":"Do\u2019s and don\u2019ts of reporting encephalopathy","author":"Boy","year":"2021","unstructured":"Boy\n              K.\n            \n           Do\u2019s and don\u2019ts of reporting encephalopathy. August 16, 2021. Accessed January 9, 2024. https:\/\/hiacode.com\/blog\/education\/coding-tip-reporting-encephalopathy"},{"issue":"2","key":"ref-472283","series-title":"Cureus","first-page":"e22102","article-title":"Inpatient management of encephalopathy","volume":"14","author":"Reddy","year":"2022","unstructured":"Reddy\n              P.\n            \n            \n              Culpepper\n              K.\n            \n           Inpatient management of encephalopathy. Cureus. 2022;14(2)e22102\n          10.7759\/cureus.22102\n          35291547\n          PMC8917954"},{"key":"ref-472285","series-title":"Encephalopathy","author":"Boy","year":"2023","unstructured":"Boy\n              K.\n            \n           Encephalopathy. July 10, 2023.  Accessed April 1, 2024. https:\/\/hiacode.com\/blog\/education\/encephalopathy"},{"key":"ref-472286","series-title":"Taking the mystery out of encephalopathy","author":"Valdez","year":"2018","unstructured":"Valdez\n              D.\n            \n           Taking the mystery out of encephalopathy. 2018"},{"key":"ref-472287","series-title":"Denied!","author":"Johnson","year":"2024","unstructured":"Johnson\n              L. M.\n            \n           Denied!. January 22, 2024. Accessed April 23, 2024. https:\/\/icd10monitor.medlearn.com\/denied\/"},{"key":"ref-472289","series-title":"International Classification of Diseases, Tenth Revision, Clinical Modification","author":"National Center for Health Statistics (NCHS)","year":"2024","unstructured":"National Center for Health Statistics (NCHS)\n          . International Classification of Diseases, Tenth Revision, Clinical Modification. 2024"},{"key":"ref-472288","series-title":"Brain Behav Immun-Health","first-page":"100136","article-title":"Acute encephalopathy is associated with worse outcomes in COVID-19 patients","volume":"8","author":"Shah","year":"2020","unstructured":"Shah\n              V. A.\n            \n            \n              Nalleballe\n              K.\n            \n            \n              Zaghlouleh\n              M. E.\n            \n            \n              Onteddu\n              S.\n            \n           Acute encephalopathy is associated with worse outcomes in COVID-19 patients. Brain Behav Immun-Health. 2020;8:100136\n          10.1016\/j.bbih.2020.100136\n          32904923\n          PMC7462562"},{"key":"ref-472290","series-title":"Physicians advisor\u2019s corner: Clearing the confusion about encephalopathy","author":"Maguir","year":"2019","unstructured":"Maguir\n              A. B.\n            \n           Physicians advisor\u2019s corner: Clearing the confusion about encephalopathy. November 22, 2019. Accessed July 2, 2024.\n          https:\/\/www.premierhealth.com\/your-health\/articles\/premier-pulse\/physicians-advisor-s-corner-clearing-the-confusion-about-encephalopathy"},{"key":"ref-472291","series-title":"A CDI revolution unfolding","author":"Krauss","year":"2019","unstructured":"Krauss\n              G.\n            \n           A CDI revolution unfolding. March 18, 2019. Accessed April 23, 2024.\n          https:\/\/medlearn.com\/a-cdi-revolution-unfolding\/"},{"key":"ref-472292","series-title":"Denials management toolkit","author":"Edwards","year":"2023","unstructured":"Edwards\n              M. E.\n            \n            \n           Denials management toolkit.  2023. Accessed April 23, 2024.\n          https:\/\/bok.ahima.org\/topics\/coding-compliance-and-revenue-cycle\/denials-management-toolkit\/"},{"issue":"16","key":"ref-472293","series-title":"CDI Strategies","article-title":"ACDIS update: ACDIS poll reveals members\u2019 top 10 queried diagnoses","volume":"12","author":"Association of Clinical Documentation Integrity Specialists (ACDIS)","year":"2018","unstructured":"Association of Clinical Documentation Integrity Specialists (ACDIS)\n           ACDIS update: ACDIS poll reveals members\u2019 top 10 queried diagnoses. CDI Strategies. 2018;12(16"},{"issue":"55","key":"ref-472294","series-title":"CDI Strategies","article-title":"Q Encephalopathy due to UTI versus metabolic encephalopathy due to UTI","volume":"12","author":"Pinson","year":"2018","unstructured":"Pinson\n              R.\n            \n           Q Encephalopathy due to UTI versus metabolic encephalopathy due to UTI. CDI Strategies. 2018;12(55"},{"issue":"9","key":"ref-472284","series-title":"The Livanta Claims Review Advisor","article-title":"Higher-weighted diagnosis related groups (HWDRG) validation - Encephalopathy","volume":"1","author":"Livanta QIO","year":"2022","unstructured":"Livanta QIO\n           Higher-weighted diagnosis related groups (HWDRG) validation - Encephalopathy. The Livanta Claims Review Advisor. 2022;1(9"},{"key":"ref-472295","series-title":"CDI queries work best if the recipient is kept in mind","author":"Remer","year":"2024","unstructured":"Remer\n              E.\n            \n           CDI queries work best if the recipient is kept in mind. March 7, 2024. Accessed July 2, 2024.\n          https:\/\/medlearn.com\/cdi-queries-work-best-if-the-recipient-is-kept-in-mind\/"},{"issue":"181","key":"ref-472296","series-title":"CDI Blog","article-title":"From the forum: Denial proofing queries","volume":"11","author":"ACDIS","year":"2018","unstructured":"ACDIS\n           From the forum: Denial proofing queries. CDI Blog. 2018;11(181"},{"key":"ref-472297","series-title":"Practice brief: Clinical validation","author":"Carr","year":"2023","unstructured":"Carr\n              K. M.\n            \n            \n           Practice brief: Clinical validation. 2023. Accessed August 21, 2023.\n          https:\/\/www.ahima.org\/landing-pages\/clinical-validation-practice-brief\/"},{"key":"ref-472298","series-title":"ICD-10-CM official guidelines for coding and reporting","author":"CMS","year":"2024","unstructured":"CMS\n          . ICD-10-CM official guidelines for coding and reporting.; 2024."},{"issue":"4","key":"ref-472299","series-title":"Coding Clinic","article-title":"Encephalopathy associated with cerebrovascular accident","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2017","unstructured":"American Hospital Association (AHA)\n           Encephalopathy associated with cerebrovascular accident. Coding Clinic. 2017;Second Quarter(4"},{"issue":"8","key":"ref-472300","series-title":"Coding Clinic","article-title":"Static encephalopathy due to epilepsy","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2021","unstructured":"American Hospital Association (AHA) \n           Static encephalopathy due to epilepsy. Coding Clinic. 2021;Second Quarter(8"},{"issue":"3","key":"ref-472301","series-title":"Coding Clinic","article-title":"Hepatic encephalopathy","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2016","unstructured":"American Hospital Association (AHA) \n           Hepatic encephalopathy. Coding Clinic. 2016;Second Quarter(3"},{"issue":"3","key":"ref-472302","series-title":"Coding Clinic","article-title":"Encephalopathy due to diabetic hypoglycemia","volume":"Third Quarter","author":"American Hospital Association (AHA)","year":"2016","unstructured":"American Hospital Association (AHA) \n           Encephalopathy due to diabetic hypoglycemia. Coding Clinic. 2016;Third Quarter(3"},{"issue":"4","key":"ref-472303","series-title":"Coding Clinic","article-title":"Encephalopathy due to sepsis","volume":"Second Quarter","author":"American Hospital Association (AHA)","year":"2017","unstructured":"American Hospital Association (AHA) \n           Encephalopathy due to sepsis. Coding Clinic. 2017;Second Quarter(4"},{"key":"ref-472304","series-title":"ICD-10-CM\/PCS MS-DRG v41.1 definitions manual","author":"Centers for Medicare and Medicaid Services (CMS)","year":"2024","unstructured":"Centers for Medicare and Medicaid Services (CMS)\n          . ICD-10-CM\/PCS MS-DRG v41.1 definitions manual. 2024. Accessed August 2, 2024.\n          https:\/\/www.cms.gov\/icd10m\/FY2024-version41.1-fullcode-cms\/fullcode_cms\/P0031.html"},{"issue":"39","key":"ref-472305","series-title":"CDI Strategies","article-title":"Q Denials for encephalopathy","volume":"12","author":"Frady","year":"2018","unstructured":"Frady\n              A.\n            \n           Q Denials for encephalopathy. CDI Strategies. 2018;12(39"}],"container-title":["Advances in Health Information Science and Practice"],"original-title":[],"link":[{"URL":"https:\/\/ahisp.kglmeridian.com\/view\/journals\/3995\/1\/2\/article-VZZE2856.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/ahisp.kglmeridian.com\/downloadpdf\/journals\/3995\/1\/2\/article-VZZE2856.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/ahisp.kglmeridian.com\/downloadpdf\/journals\/3995\/1\/2\/article-VZZE2856.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T00:55:52Z","timestamp":1770771352000},"score":1,"resource":{"primary":{"URL":"https:\/\/ahisp.kglmeridian.com\/view\/journals\/3995\/1\/2\/article-VZZE2856.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025]]},"references-count":52,"journal-issue":{"issue":"2"},"URL":"https:\/\/doi.org\/10.63116\/vzze2856","relation":{},"ISSN":["3066-5825"],"issn-type":[{"value":"3066-5825","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025]]}}}